BBs and HD

Q: 56 years old male is admitted to ICU with his prescribed Beta-Blocker (BB) overdose. Patient is severely hypotensive and bradycardic. A transcutaneous pacemaker is applied. To resolve the overdose, hemodialysis (HD) is suggested. Which of the following BBs may not get removed by HD? - select one

A) Metoprolol

B) Atenolol

C) Nadolol 

D) Sotalol 

E) Acebutolol 

Answer: A

Hemodialysis (HD) can be instituted in extreme BB overdose when all other remedies fail. However, not all B-blockers respond to dialysis.

B-blockers that respond to HD are mostly low protein-binding and water-soluble. Atenolol has been described as the most responsive B-blocker. Nadolol and sotalol are also removed by hemodialysis. Acebutolol is also dialyzable.

B-blockers that do not respond to HD are propranolol, metoprolol, and timolol.

#toxicity

#pharmacology

References:

1. Bouchard J, Shepherd G, Hoffman RS, Gosselin S, Roberts DM, Li Y, Nolin TD, Lavergne V, Ghannoum M; EXTRIP workgroup. Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup. Crit Care. 2021 Jun 10;25(1):201. doi: 10.1186/s13054-021-03585-7. PMID: 34112223; PMCID: PMC8194226.

2. Rotella JA, Greene SL, Koutsogiannis Z, Graudins A, Hung Leang Y, Kuan K, Baxter H, Bourke E, Wong A. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020 Oct;58(10):943-983. doi: 10.1080/15563650.2020.1752918. Epub 2020 Apr 20. PMID: 32310006.

3. Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2023 Jul 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/