📋 Indications & Clinical Dosage
*Treatment of angina in patients in normal sinus rhythm:*
Adult: Initially 5 mg twice daily for 3-4 weeks, then increased if necessary to 7.5 mg twice daily; reduced if not tolerated to 2.5-5 mg twice daily, heart rate at rest should not be allowed to fall below 50 beats per minute
Elderly: Initially 2.5 mg twice daily, heart rate at rest should not be allowed to fall below 50 beats per minute.
*Mild to severe chronic heart failure:*
Adult: Initially 5 mg twice daily for 2 weeks, then increased if necessary to 7.5 mg twice daily; reduced if not tolerated to 2.5 mg twice daily, heart rate at rest should not be allowed to fall below 50 beats per minute.
Children: Not recommended.
⛔ Contraindications
Cardiogenic shock, acute myocardial infarction, congenital QT syndrome. Do not initiate for angina if heart rate below 70 beats per min or in chronic heart failure below 75 beats per minute, severe hepatic or renal impairment, immediately after
cerebrovascular accident, patients dependent on pacemaker, second- and third-degree heart block, severe hypotension, sick-sinus syndrome, sino-atrial block, unstable angina, unstable or acute heart failure.
⚠️ Precautions & Warnings
Atrial fibrillation or other arrhythmias (treatment ineffective), elderly, in angina, consider stopping if there is no or limited symptom improvement after 3 months, intra-ventricular conduction defects, mild to moderate hypotension (avoid if severe), retinitis pigmentosa, renal impairment use with caution if eGFR less than 15 ml/minute/1.73m2
🔄 Drug Interactions
CYP3A4 inducers and inhibitors, thiazides, loop diuretics, Ca Channel blockers, drugs that prolong the QT interval, grapefruit juice.
⚠️ Adverse Reactions / Side Effects
Atrial fibrillation, visual disturbances blurred vision, bradycardia, dizziness, first-degree heart block, headache, phosphenes, ventricular extrasystoles, angioedema, constipation, diarrhoea, dyspnea, eosinophilia, hyperuricaemia, muscle cramps, nausea, palpitations, raised plasma-creatinine concentration, rash, supraventricular extrasystoles, vertigo. Rare Second and third-degree heart block, sick sinus syndrome
🤰 Pregnancy & Lactation Safety
Pregnancy Risk:
Contraindicated in pregnancy,
Lactation / Breastfeeding:
Contraindicated
📚 Official Regulatory & Clinical References
- Drug Regulatory Authority of Pakistan (DRAP): Drug Registration, S.R.O. Price Gazettes & National Essential Medicines List (NEML).
- World Health Organization (WHO): Collaborating Centre for Drug Statistics Methodology (ATC/DDD Index).
- Formulary Standards: British National Formulary (BNF) & Pakistan National Formulary (PNF) guidelines.