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Carvedilol Vs Atenolol

carvedilol vs atenolol

Comparing carvedilol and metoprolol: results of the COMET trial

  • The Carvedilol or Metoprolol European Trial (COMET) compared overall mortality in patients with heart failure, randomised to receive either carvedilol or metoprolol tartrate.4 The doses used were carvedilol 25 mg twice daily and metoprolol tartrate 50 mg twice daily. The results of the trial showed that carvedilol was associated with a 15% relative risk reduction in all cause mortality, compared to metoprolol tartrate.5 Carvedilol extended median survival by 1.4 years (95% CI: 0.5-2.3 years) compared with metoprolol and was associated with significantly lower rates of death from stroke and new-onset diabetes. There were no observed differences between carvedilol and metoprolol tartrate in rate of hospitalisation, adverse events or drug withdrawal.
  • Based on the results of the COMET trial, the authors concluded that carvedilol, at a dose of 25 mg twice daily, provides superior morbidity and mortality benefit compared to metoprolol tartrate at a dose of 50 mg twice daily. However there is some controversy surrounding the conclusions drawn from this study, with debate focusing on whether the doses of the two drugs were comparable. It has been suggested that metoprolol tartrate should have been titrated to a higher dose (up to 200 mg per day). However, there is no agreement on what the optimal dose equivalence between the two drugs should be and in addition it is unproven whether higher doses of metoprolol tartrate confer lower mortality.

Carvedilol may be an option if metoprolol succinate is poorly tolerated.

There is no advantage in changing to carvedilol for people who are already taking metoprolol succinate at effective doses. However, carvedilol may be an option if metoprolol succinate is poorly tolerated. In patients with heart failure who have not previously used a beta-blocker, carvedilol may be considered as the first choice agent.

If a decision is made to switch from metoprolol succinate to carvedilol there are some important considerations.

Strategies for changing to carvedilol

Two strategies have been suggested for changing from metoprolol succinate to carvedilol; either a non-overlapping protocol where a straight switch is made, or an over-lapping protocol where the dose of metoprolol succinate is gradually reduced whilst simultaneously up-titrating carvedilol.8 Whichever method is used, co-existing heart failure medication should be stable and the patient should be relatively euvolaemic.

An overlapping method may be considered if the patient is taking high doses of metoprolol. In this method, the dose of metoprolol is gradually reduced while the dose of carvedilol is increased. Most patients seem to tolerate a simple approach without an overlap period, particularly if they are taking relatively low doses (i.e. <95 mg daily) of metoprolol. 8 In this method, the metoprolol is stopped upon initiation of the carvedilol, which is titrated to the target or maximum tolerated dose.

Initiating carvedilol in patients with stable chronic heart failure.

All other medication (e.g. digoxin, diuretics, ACE inhibitors) should be stabilised prior to starting carvedilol

  • Carvedilol should be given twice daily
  • Recommended starting dose is 3.125 mg, twice daily, for two weeks
  • Increase dose at intervals of at least two weeks, to 6.25 mg, 12.5 mg then 25 mg, twice daily, as tolerated
  • Maximum dose for patients with severe CHF, or weighing less than 85 kg, is 25 mg twice daily. In patients with mild to moderate CHF and over 85 kg, the maximum recommended dose is 50 mg twice daily
  • Signs of intolerance to carvedilol include bradycardia (<50 bpm), systolic BP <80 mmHg or fluid retention

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