Pindolol (Visken) is a non-selective beta-receptor blocker with some sympathomimetic activity. It is used in the management of hypertension, angina, and to augment the effects of antidepressants.
Pindolol Uses:
-
Hypertension:
- Management of hypertension.
Note: Beta-blockers are not recommended for first-line therapy.
-
Off Label Use of Pindolol in Adults:
- Antidepressant augmentation
- Atrial fibrillation (rate-control)
Pindolol Dose in Adults
Pindolol Dose as an alternative agent in the treatment of Hypertension:
- Oral: Initial: 5 mg twice a day;
- Dependent on the patient's reaction, increase the dose by 10 mg every three to four weeks, up to 30 mg twice a day;
- maximum: 60 mg/day
Pindolol Dose in the treatment of Antidepressant augmentation (off-label):
- Oral: 2.5 to 5 mg 3 times a day
Pindolol Dose in the treatment of Atrial fibrillation (for rate control):
- Initial dose: 5 mg twice daily; the dose may be increased to 15 mg twice daily at weekly intervals.
- May use in combination with digoxin.
Pindolol Dose in Children
Not recommended for use in children.
Pregnancy Risk Factor B
- Animal reproduction studies did not show any adverse effects.
- Pindolol crosses over the placenta, and is measured in cord blood and amniotic liquid.
- During pregnancy, pindolol's clearance and distribution volume are higher.
- In utero beta-blocker exposure has been linked to adverse events such as hypoglycemia and fetal/neonatal bradycardia.
- It is recommended that infants are monitored at birth in a safe environment.
- Preeclampsia and chronic maternal hypertension that are not treated can also cause adverse events in the infant, mother, and fetus.
- Beta-blockers can be used to treat hypertension during pregnancy. Each guideline has its own specific recommendations.
- While other agents may be preferred, pindolol might still be an option.
Pindolol use during breastfeeding:
- Breast milk contains pindolol.
- Manufacturers do not recommend breastfeeding.
Pindlol Dose in Kidney Disease:
- There are no dosage adjustments provided in the drug manufacturer’s labeling;
- however, others have recommended that no dosage adjustment is required in renal impairment including those patients with GFR <10 mL/minute ;
- use with caution in uremic patients as renal clearance is reduced.
Pindlol Dose in Liver Disease:
- There are no specific dosage adjustments provided in the drug manufacturer’s labeling;
- However, a dose reduction may be necessary in cirrhotic patients due to significantly prolonged elimination half-life (may be 10 times as long compared to subjects with normal hepatic function).
Common Side Effects of Pindolol:
-
Cardiovascular:
- Edema
Less Common Side Effects of Pindolol:
-
Cardiovascular:
- Bradycardia
- Claudication
- Cold Extremities
- Heart Block
- Hypotension
- Syncope
- Tachycardia
- Palpitations
-
Central Nervous System:
- Insomnia
- Dizziness
- Fatigue
- Nervousness
- Abnormal Dreams
- Anxiety
- Lethargy
-
Dermatologic:
- Hyperhidrosis
- Pruritus
-
Endocrine & Metabolic:
- Weight Gain
-
Gastrointestinal:
- Nausea
- Diarrhea
- Vomiting
-
Genitourinary:
- Impotence
- Pollakiuria
-
Hepatic:
- Increased Serum ALT
- Increased Serum AST
-
Neuromuscular & Skeletal:
- Myalgia
- Arthralgia
- Weakness
- Muscle Cramps
-
Ophthalmic:
- Burning Sensation Of Eyes
- Eye Discomfort
- Visual Disturbance
-
Renal:
- Polyuria
-
Respiratory:
- Dyspnea
- Wheezing
Contraindications to Pindolol:
- Bronchial asthma;
- Cardiogenic shock
- Heart block, second- or third-degree, is not possible in patients who have an artificially implanted pacemaker.
- Symptoms of severe cardiac disease
- Bradycardia severe
- There is not much evidence of cross-reactivity between beta-blockers and allergens.
- Cross-sensitivity is possible due to similar chemical structures and/or pharmacologic effects.
Canadian labeling:Additional contraindications not listed in the US labeling:
- Hypersensitivity/Allergy to pindolol, other beta-blockers or any component of the formulation;
- Grave chronic obstructive lung disease
- Right ventricular failure secondary pulmonary hypertension
- Anesthesia using agents that cause myocardial depression
- Prinzmetal angina (variant angina);
- sick sinus syndrome;
- Grave peripheral arterial circulation disorders
- Untreated pheochromocytoma
Warnings and precautions
-
Anaphylactic reactions
- Be cautious if you have had severe allergic reactions to allergens in the past.
- Beta-blocker users can be more susceptible to repeated exposures.
- Treatment for anaphylaxis in beta-blocker users may not be successful or may have negative side effects.
-
Bronchospastic Disease:
- Patients with bronchospastic diseases should avoid beta-blockers. If they do, they should be monitored closely and used with caution.
-
Conductive abnormality
- Before you start, consider preexisting conditions like sick sinus syndrome.
-
Diabetes:
- Patients with diabetes mellitus should be cautious when using this medication. It may cause hypoglycemia to worsen and/or mask symptoms.
-
Heart failure (HF):
- Patients with compensated HF should be treated with caution and monitored for any signs of deterioration.
- Consider temporary withholding pindolol or reducing the dosage if the condition gets worse.
- Before beta-blocker is initiated, patients should be stable on the heart failure regimen.
- Beta-blocker therapy should not be taken at high doses and should be titrated slowly.
- It might be essential to change other prescription drugs (ACE inhibitors or diuretics).
- It has not been shown that beta-blockers with intrinsic sympathomimetic activities (eg, pindololol), are of any importance in HF.
-
Hepatic impairment
- Take care when you have a hepatic impairment
- With liver impairment, pindolol levels can rise dramatically.
-
Myasthenia gravis:
- Patients with myasthenia gravis should be cautious.
-
Raynaud and peripheral vascular disease (PVD).
- It can cause or exacerbate arterial insufficiency symptoms in patients with Raynaud and PVD.
- Be cautious and watch for arterial obstruction.
-
Untreated Pheochromocytoma
- Before any beta-blocker can be used, it is necessary to have adequate alpha-blockade.
-
Angina Prinzmetal version:
- Prinzmetal variant Angina should not be treated with beta-blockers that do not block alpha1 adrenergic receptor activity.
- Unopposed alpha1 adrenergic receptive receptors can cause coronary vasoconstriction, which can lead to worsening of anginal symptoms.
-
Psoriasis:
- Although beta-blocker usage has been associated with psoriasis exacerbation or induction, cause and effect are not yet clear.
-
Renal impairment
- Patients with impaired renal function should be cautious.
-
Thyroid disease:
- Hyperthyroidism may be disguised (eg, Tachycardia).
- Thyrotoxicosis should be treated and monitored if it is suspected.
- Rapid withdrawal can worsen hyperthyroidism symptoms or cause a thyroid storm.
Pindolol: Drug Interaction
|
Acetylcholinesterase Inhibitors |
May enhance the bradycardic effect of Beta-Blockers. |
|
Alfuzosin |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Alpha1-Blockers |
Beta-Blockers may enhance the orthostatic hypotensive effect of Alpha1Blockers. The risk associated with ophthalmic products is probably less than systemic products. |
|
Aminoquinolines (Antimalarial): |
May decrease the metabolism of Beta-Blockers. |
|
Amiodarone |
May enhance the bradycardic effect of Beta-Blockers. Possibly to the point of cardiac arrest. Amiodarone may increase the serum concentration of Beta-Blockers. |
|
Amphetamines |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Antipsychotic Agents (Phenothiazines) |
May enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents (Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of Beta-Blockers. |
|
Antipsychotic Agents (Second Generation [Atypical]) |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). |
|
Barbiturates |
May decrease the serum concentration of Beta-Blockers. |
|
Barbiturates |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Benperidol |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Bradycardia-Causing Agents |
May enhance the bradycardic effect of other Bradycardia-Causing Agents. |
|
Bretylium |
May enhance the bradycardic effect of Bradycardia-Causing Agents. Bretylium may also enhance atrioventricular (AV) blockade in patients receiving AV blocking agents. |
|
Brigatinib |
May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. |
|
Brimonidine (Topical |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Bupivacaine |
Beta-Blockers may increase the serum concentration of Bupivacaine. |
|
Calcium Channel Blockers (Nondihydropyridine) |
May enhance the hypotensive effect of BetaBlockers. Bradycardia and signs of heart failure have also been reported. Calcium Channel Blockers (Nondihydropyridine) may increase the serum concentration of Beta-Blockers. Exceptions: Bepridil. |
|
Cardiac Glycosides |
Beta-Blockers may enhance the bradycardic effect of Cardiac Glycosides. |
|
Cholinergic Agonists |
Beta-Blockers may make Cholinergic Agonists' harmful or toxic effects worse. The possibilities for bronchoconstriction and aberrant cardiac conduction are of special concern. Management: Use cautious while combining these drugs, and keep an eye out for conduction issues. Because methacholine may cause further bronchoconstriction when used with any beta blocker, avoid using it. |
|
Dexmethylphenidate |
Can lessen an antihypertensive drug's therapeutic impact. |
|
Diazoxide |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Dipyridamole |
Could make beta-blockers' bradycardic impact stronger. |
|
Disopyramide |
Could make beta-blockers' bradycardic impact stronger. Beta-blockers might make Disopyramide's adverse inotropic impact worse. |
|
DULoxetine |
The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications. |
|
EPINEPHrine (Nasal) |
The hypertensive impact of EPINEPHRINE may be enhanced by beta-blockers like Nonselective (Nasal). |
|
EPINEPHrine (Oral Inhalation) |
The hypertensive impact of EPINEPHRINE may be enhanced by beta-blockers like Nonselective (Oral Inhalation). |
|
Epinephrine (Racemic) |
Epinephrine's hypertensive action may be enhanced by beta-blockers like Nonselective (Racemic). |
|
EPINEPHrine (Systemic) |
The hypertensive impact of EPINEPHRINE may be enhanced by beta-blockers like Nonselective (Systemic). |
|
Erdafitinib |
OCT2 Substrates' serum concentration can rise. |
|
Flecainide |
May intensify Pindolol's bradycardic impact. Pindolol's unfavourable inotropic effects might even be exacerbated. |
|
Herbs (Hypertensive Properties) |
May lessen the effectiveness of antihypertensive agents. |
|
Herbs (Hypotensive Properties) |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Hypotension-Associated Agents |
The hypotensive action of hypotension-associated agents may be strengthened by blood pressure lowering medications. |
|
Insulins |
Beta-Blockers might improve insulin's ability to lower blood sugar. |
|
Ivabradine |
Bradycardia-Causing Agents may intensify Ivabradine's bradycardic impact. |
|
Lacosamide |
Bradycardia-Causing Substances may intensify Lacosamide's AV-blocking effects. |
|
Levodopa-Containing Products |
Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications. |
|
Lidocaine (Systemic) |
Beta-blockers might boost the level of lidocaine in the blood (Systemic). |
|
Lidocaine (Topical) |
Beta-blockers might boost the level of lidocaine in the blood (Topical). |
|
Lormetazepam |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Mepivacaine |
Mepivacaine's serum levels may rise after taking beta-blockers. |
|
Methoxyflurane |
May enhance the hypotensive effect of Beta-Blockers. |
|
Methylphenidate |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Midodrine |
May enhance the bradycardic effect of Bradycardia-Causing Agents. |
|
Molsidomine |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Naftopidil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nicergoline |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nicorandil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
NIFEdipine |
May enhance the hypotensive effect of Beta-Blockers. NIFEdipine may enhance the negative inotropic effect of Beta-Blockers. |
|
Nitroprusside |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. |
|
Nonsteroidal Anti-Inflammatory Agents |
May diminish the antihypertensive effect of BetaBlockers. |
|
Opioids (Anilidopiperidine) |
May enhance the bradycardic effect of Beta-Blockers. Opioids (Anilidopiperidine) may enhance the hypotensive effect of Beta-Blockers. |
|
Pentoxifylline |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Pholcodine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. |
|
Phosphodiesterase 5 Inhibitors |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Propafenone |
May increase the serum concentration of Beta-Blockers. Propafenone possesses some independent beta blocking activity. |
|
Prostacyclin Analogues |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Quinagolide |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Regorafenib |
May enhance the bradycardic effect of Beta-Blockers. |
|
Reserpine |
May enhance the hypotensive effect of Beta-Blockers. |
|
Rifamycin Derivatives |
May decrease the serum concentration of Beta-Blockers. Exceptions: Rifabutin. |
|
Ruxolitinib |
May enhance the bradycardic effect of Bradycardia-Causing Agents. Management: Ruxolitinib Canadian product labeling recommends avoiding use with bradycardia-causing agents to the extent possible. |
|
Selective Serotonin Reuptake Inhibitors |
May raise the level of beta-blockers in the serum. Citalopram, Escitalopram, and FluvoxaMINE are exceptions. |
|
Sulfonylureas |
Beta-Blockers may enhance the hypoglycemic effect of Sulfonylureas. Cardioselective beta-blockers (eg, acebutolol, atenolol, metoprolol, and penbutolol) may be safer than nonselective beta-blockers. All beta-blockers appear to mask tachycardia as an initial symptom of hypoglycemia. Ophthalmic beta-blockers are probably associated with lower risk than systemic agents. |
|
Terlipressin |
May enhance the bradycardic effect of Bradycardia-Causing Agents. |
|
Tofacitinib |
May enhance the bradycardic effect of Bradycardia-Causing Agents. |
|
Yohimbine |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Risk Factor D (Consider therapy modification) |
|
|
Alpha2-Agonists |
May enhance the AV-blocking effect of Beta-Blockers. Sinus node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound hypertensive effect of Alpha2Agonists. This effect can occur when the Alpha2-Agonist is abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists are unavailable. Exceptions: Apraclonidine. |
|
Amifostine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. |
|
Ceritinib |
|
|
Dronedarone |
May enhance the bradycardic effect of Beta-Blockers. Dronedarone may increase the serum concentration of Beta-Blockers. This likely applies only to those agents that are metabolized by CYP2D6. Management: Use lower initial beta-blocker doses; adequate tolerance of the combination, based on ECG findings, should be confirmed prior to any increase in betablocker dose. |
|
Ergot Derivatives |
Beta-Blockers may enhance the vasoconstricting effect of Ergot Derivatives. Exceptions: Nicergoline. |
|
Fingolimod |
Beta-Blockers may enhance the bradycardic effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and beta-blockers if possible. If coadministration is necessary, patients should have overnight continuous ECG monitoring conducted after the first dose of fingolimod. Monitor patients for bradycardia. |
|
Grass Pollen Allergen Extract (5 Grass Extract) |
Beta-Blockers may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). More specifically, Beta-Blockers may inhibit the ability to effectively treat severe allergic reactions to Grass Pollen Allergen Extract (5 Grass Extract) with epinephrine. Some other effects of epinephrine may be unaffected or even enhanced (e.g., vasoconstriction) during treatment with Beta-Blockers. |
|
Monoamine Oxidase Inhibitors |
May enhance the hypotensive effect of Pindolol. Management: Canadian labeling for pindolol states that concurrent use with a monoamine oxidase inhibitor is not recommended. |
|
Obinutuzumab |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. |
|
Siponimod |
Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia. |
|
Tafenoquine |
OCT2 Substrates' serum concentration can rise. Management: If using OCT2 substrates with tafenoquine cannot be avoided, watch closely for any signs of toxicity and take into account using a lower dose of the OCT2 substrate in accordance with the labelling of that substrate. |
|
Theophylline Derivatives |
Beta-Blockers (Nonselective) may diminish the bronchodilatory effect of Theophylline Derivatives. |
|
Risk Factor X (Avoid combination) |
|
|
Beta2-Agonists |
Beta-Blockers (Nonselective) may diminish the bronchodilatory effect of Beta2Agonists. |
|
Bromperidol |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. |
|
Floctafenine |
May enhance the adverse/toxic effect of Beta-Blockers. |
|
Methacholine |
Beta-Blockers may enhance the adverse/toxic effect of Methacholine. |
|
Rivastigmine |
May enhance the bradycardic effect of Beta-Blockers. |
Monitoring Parameters:
- Blood pressure,
- heart rate,
- respiratory function
Hypertension Guidelines:
- The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:
-
Confirmed hypertension and known CVD or 10-year ASCVD risk ≥10%:
- Target blood pressure of <130/80 mm Hg is recommended.
-
Confirmed hypertension without markers of increased ASCVD risk:
- Target blood pressure <130/80 mm Hg may be reasonable
How to administer Pindolol?
- Oral: May be administered without regard to meals.
Mechanism of action of Pindolol:
- It blocks beta-1 and beta-2 receptors, and has mild intrinsic sympathomimetic activities.
- Pindolol can have negative inotropic or chronotropic effects, and can significantly slow down AV nodal conduction.
- The mechanism of augmentation of antidepressants is thought to be via serotonin 1A antagonism.
Absorption:
- Rapid, >95%
Protein binding:
- 40%
Metabolism:
- Hepatic (60% to 65%) to conjugates
Half-life elimination:
- 3 to 4 hours; prolonged in the elderly (average 7 hours; up to 15 hours reported), and cirrhosis (range: 2.5 to 30 hours)
Time to peak serum concentrations:
- ~1 hour
Excretion:
- Urine (35% to 40% as unchanged drug);
- feces (6% to 9%)
International Brands of Pindolol:
- APO-Pindol
- DOM-Pindolol
- PMS-Pindolol
- SANDOZ Pindolol
- TEVA-Pindolol
- Visken
- Apo-Pindolol
- Barbloc
- Carvisken
- Decreten
- Dranolis
- Hexapindol
- Huma-Pindol
- Pinden
- Pindol
- Pindomex
- Pinloc
- Pithiorol
- Pollight
- Pyndale
- Treparasen
- Visken
Pindolol Brand Names in Pakistan:
No Brands Available in Pakistan.
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