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Pharmacologic class: Beta-adrenergic blocker (nonselective)
Therapeutic class: Antihypertensive
Pregnancy risk category C
Blocks stimulation of cardiac beta1-adrenergic receptor sites and pulmonary beta2-adrenergic receptor sites. Shows intrinsic sympathomimetic activity, causing slowing of heart rate, decreased myocardial excitability, reduced cardiac output, and decreased renin release from kidney.
Capsules (extended-release): 10 mg, 20 mg, 40 mg, 80 mg
Tablets: 3.125 mg, 6.25 mg, 12.5 mg, 25 mg
Indications and dosages
Adults: Initially, 6.25 mg P.O. b.i.d. (Coreg). May be increased q 7 to 14 days to a maximum dosage of 25 mg b.i.d. Or, 20 mg P.O. daily (Coreg CR). If tolerated, using standing systolic pressure about 1 hour after dosing, maintain dosage of Coreg CR for 7 to 14 days; then increase to 40 mg once daily if needed based on trough systolic standing blood pressure. Maintain this dosage for 7 to 14 days and adjust to 80 mg once daily if tolerated and needed. Total daily dose of Coreg CR shouldn't exceed 80 mg.
➣ Heart failure caused by ischemia or cardiomyopathy
Adults: Initially, 3.125 mg P.O. b.i.d. (Coreg) for 2 weeks. May increase to 6.25 mg b.i.d. Dosage may be doubled q 2 weeks as tolerated, not to exceed 25 mg b.i.d. in patients weighing less than 85 kg (187 lb) or 50 mg b.i.d. in patients weighing more than 85 kg. Or, 10 mg P.O. daily (Coreg CR) for 2 weeks. If tolerated, increase dosage to 20 mg, 40 mg, and 80 mg over successive intervals of at least 2 weeks.
➣ Left ventricular dysfunction following myocardial infarction
Adults: Initially, 6.25 mg P.O. b.i.d. (Coreg); increase after 3 to 10 days to 12.5 mg b.i.d. (based on tolerability), then increase to target dosage of 25 mg b.i.d. A lower starting dose (3.125 mg b.i.d.) or slower titration may be used if clinically indicated. Or, 20 mg P.O. once daily (Coreg CR); increase after 3 to 10 days to 40 mg daily (based on tolerability), then increase to target dose of 80 mg daily. A lower starting dose may be used (10 mg daily) or the rate of up titration may be slowed if clinically indicated.
• Angina pectoris
• Idiopathic cardiomyopathy
• Hypersensitivity to drug
• Uncompensated heart failure
• Pulmonary edema
• Cardiogenic shock
• Bradycardia or heart block
• Severe hepatic impairment
• Bronchial asthma, bronchospasm
Use cautiously in:
• renal or hepatic impairment, pulmonary disease, diabetes mellitus, hypoglycemia, thyrotoxicosis, peripheral vascular disease, hypotension, respiratory depression
• elderly patients
• pregnant or breastfeeding patients
• Ensure that patient is hemodynamically stable and fluid retention has been minimized before starting therapy.
• Give immediate-release form with food to slow absorption and minimize orthostatic hypotension.
• Give extended-release form in the morning with food and instruct patient to swallow capsule whole.
• For patients who can't swallow capsules whole, carefully open capsules and sprinkle contents on applesauce; have patient swallow contents immediately without chewing. Don't use warm applesauce; doing so could affect the modified-release properties of this formulation.
• When drug is used to treat heart failure, check apical pulse before administering. If it's below 60 beats/minute, withhold dosage and contact prescriber.
• When drug is used for hypertension, check standing systolic pressure about 1 hour after dosing for use as a guide for patient tolerance.
• Be aware that addition of diuretic may cause additive effects and may worsen orthostatic hypotension.
• Know that full antihypertensive effect takes 7 to 14 days.
☞ Don't withdraw drug abruptly, because this may lead to withdrawal phenomenon (angina exacerbation, myocardial infarction, ventricular arrhythmias, and even death).
CNS: dizziness, fatigue, anxiety, depression, insomnia, memory loss, nightmares, headache, pain
CV: orthostatic hypotension, peripheral vasoconstriction, angina pectoris, chest pain, hypertension, bradycardia, heart failure, atrioventricular block
EENT: blurred or abnormal vision, dry eyes, stuffy nose, rhinitis, sinusitis, pharyngitis
GI: nausea, diarrhea, constipation
GU: urinary tract infection, hematuria, albuminuria, decreased libido, erectile dysfunction, renal dysfunction
Hematologic: bleeding, purpura, thrombocytopenia
Metabolic: hypovolemia, hypervolemia, hyperglycemia, hyponatremia, hyperuricemia, glycosuria, gout, hypoglycemia
Musculoskeletal: arthralgia, back pain, muscle cramps
Respiratory: wheezing, upper respiratory tract infection, dyspnea, bronchitis, bronchospasm, pulmonary edema
Skin: pruritus, rash
Other: weight gain, lupuslike syndrome, viral infection, anaphylaxis
Drug-drug. Antihypertensives: additive hypotension
Calcium channel blockers, general anesthetics, I.V. phenytoin: additive myocardial depression
Cimetidine: increased carvedilol toxicity
Clonidine: increased hypotension and bradycardia, exaggerated withdrawal phenomenon
Digoxin: additive bradycardia
Dobutamine, dopamine: decrease in beneficial cardiovascular effects
Insulin, oral hypoglycemics: altered efficacy of these drugs
MAO inhibitors: hypertension
Nonsteroidal anti-inflammatory drugs: decreased antihypertensive action
Rifampin, thyroid preparations: decreased carvedilol efficacy
Theophyllines: reduced theophylline elimination, antagonistic effect that decreases theophylline or carteolol efficacy
Drug-diagnostic tests. Antinuclear antibodies: increased titers
Blood urea nitrogen, glucose, lipoproteins, potassium, triglycerides, uric acid: increased levels
Drug-food. Any food: delayed drug absorption
Drug-behaviors. Acute alcohol ingestion: additive hypotension
• Watch for signs and symptoms of hypersensitivity reaction.
• Assess baseline CBC and kidney and liver function test results.
• Monitor vital signs (especially blood pressure), ECG, and exercise tolerance. Drug may alter cardiac output and cause ineffective airway clearance.
• Weigh patient daily and measure fluid intake and output to detect fluid retention.
• Measure blood glucose regularly if patient has diabetes mellitus. Drug may mask signs and symptoms of hypoglycemia.
• Instruct patient to take drug with food exactly as prescribed.
• Tell patient to take extended-release capsule in the morning with food, to swallow capsule whole, and not to chew, crush, or divide its contents.
• Instruct patient who can't swallow capsule whole to carefully open capsule, sprinkle contents on cool or cold applesauce, and swallow contents immediately without chewing. Tell patient not to store mixture for future use.
☞ Caution patient not to stop taking drug abruptly, because serious reactions may result.
• Advise patient to move slowly when sitting up or standing, to avoid dizziness or light-headedness from sudden blood pressure drop.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• Inform male patient that drug may cause erectile dysfunction. Advise him to discuss this issue with prescriber.
• Advise patient to use soft-bristled toothbrush and electric razor to avoid gum and skin injury.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and behaviors mentioned above.
Coreg CR(trade name)
Pharmacologic: beta blockers
Time/action profile (cardiovascular effects)
|PO||within 1 hr||1–2 hr||12 hr|
|PO-CR||unknown||5 hr||24 hr|
Adverse Reactions/Side Effects
Central nervous system
- dizziness (most frequent)
- fatigue (most frequent)
- weakness (most frequent)
- memory loss
- mental status changes
Ear, Eye, Nose, Throat
- blurred vision
- dry eyes
- intraoperative floppy iris syndrome
- nasal stuffiness
- bradycardia (life-threatening)
- HF (life-threatening)
- pulmonary edema (life-threatening)
- diarrhea (most frequent)
- erectile dysfunction (most frequent)
- ↓ libido
- stevens-johnson syndrome (life-threatening)
- toxic epidermal necrolysis (life-threatening)
- hyperglycemia (most frequent)
- back pain
- muscle cramps
- anaphylaxis (life-threatening)
- angioedema (life-threatening)
- drug-induced lupus syndrome
Drug-Drug interactionGeneral anesthetics, IV phenytoin, diltiazem, and verapamil may cause ↑ myocardial depression.↑ risk of bradycardia with digoxin.Amiodarone or fluconazole may ↑ levels.↑ hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates.Concurrent use with clonidine ↑ hypotension and bradycardia.May ↑ withdrawal phenomenon from clonidine (discontinue carvedilol first).Concurrent administration of thyroid preparations may ↓ effectiveness.May alter the effectiveness of insulins or oral hypoglycemic agents (dose adjustments may be necessary).May ↓ effectiveness of theophylline.May ↓ beneficial beta1-cardiovascular effects of dopamine or dobutamine.Use cautiously within 14 days of MAO inhibitor therapy (may result in hypotension/bradycardia).Cimetidine may ↑ toxicity from carvedilol.Concurrent NSAIDs may ↓ antihypertensive action.Effectiveness may be ↓ by rifampin.May ↑ serum digoxin levels.May ↑ blood levels of cyclosporine (monitor blood levels).
Availability (generic available)
- Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position.
- Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention). Patients may experience worsening of symptoms during initiation of therapy for HF.
- Hypertension: Check frequency of refills to determine adherence.
- Lab Test Considerations: May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
- May cause ↑ ANA titers.
Monitor patients receiving beta blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, seizures). Notify health care professional immediately if these signs occur.
- May cause ↑ in blood glucose levels.
Potential Nursing DiagnosesDecreased cardiac output (Side Effects)
Noncompliance (Patient/Family Teaching)
- Do not confuse carvedilol with captopril.
- Discontinuation of concurrent clonidine should be gradual, with carvedilol discontinued first over 1–2 wk with limitation of physical activity; then, after several days, discontinue clonidine.
- Oral: Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify health care professional.
- Administer with food to minimize orthostatic hypotension.
- Administer extended-release capsulesin the morning. Swallow whole; do not crush, break, or chew. Extended-release capsules may be opened and sprinkled on cold applesauce and taken immediately; do not store mixture.
- To convert from immediate-release to extended-release product, doses of 3.125 mg twice daily can be converted to 10 mg daily; doses of 6.25 mg twice daily can be converted to 20 mg daily; doses of 12.5 mg twice daily can be converted to 40 mg daily; and doses of 25 mg twice daily can be converted to 80 mg daily.
- Instruct patient to take medication as directed, at the same time each day, even if feeling well. Do not skip or double up on missed doses. Take missed doses as soon as possible up to 4 hr before next dose. Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia.
- Advise patient to make sure enough medication is available for weekends, holidays, and vacations. A written prescription may be kept in wallet in case of emergency.
- Teach patient and family how to check pulse and BP. Instruct them to check pulse daily and BP biweekly. Advise patient to hold dose and contact health care professional if pulse is <50 bpm or BP changes significantly.
- May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness until response to the drug is known.
- Advise patient to change positions slowly to minimize orthostatic hypotension, especially during initiation of therapy or when dose is increased.
- Caution patient that this medication may increase sensitivity to cold.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products, especially cold preparations, concurrently with this medication.
- Patients with diabetes should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication may mask some signs of hypoglycemia, but dizziness and sweating may still occur.
- Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
- Instruct patient to inform health care professional of medication regimen before treatment or surgery.
- Advise patient to carry identification describing disease process and medication regimen at all times.
- Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.
- Decrease in BP without appearance of detrimental side effects.
- Decrease in severity of HF.