Letter: Cold extremities and beta-blockers

The effect of withdrawal of beta-adrenergic blockade on intermittent claudication

Twenty-eight patients with intermittent claudication were studied before and one month after withdrawal of treatment with beta-adrenergic blocking drugs for hypertension, coronary heart disease or both. Heart rate, blood pressure, ankle/arm systolic blood pressure ratio and ankle pulse volume recording (PVR) at rest and after treadmill exercise were recorded, as well as walking distance, time of recovery from subjective symptoms, restitution time of pressure ratio and PVR. A control group of 14 patients, whose beta-adrenergic blocking drugs were not withdrawn, was also included. The result can be summarized as showing that withdrawal of beta-blockade was not demonstrably advantageous in patients with intermittent claudication. Significant improvement was observed only during the first month of the trial, a change which was independent of withdrawal of beta-blockade. The relief of subjective symptoms after exercise occurred significantly faster after withdrawal of nonselective beta-blockade. Otherwise, there was no difference between nonselective and cardioselective beta-adrenergic blocking drugs.

Beta-adrenoceptor-blocking agents: are pharmacologic differences relevant?

beta-Adrenoceptor-blocking agents constitute a heterogeneous group of compounds. Membrane- stabilizing (quinidine-like) effects can be demonstrated pharmacologically with most compounds, but only at relatively high concentrations. There is no evidence to suggest that this property is of clinical relevance. Some compounds have a certain selectivity for receptors of the beta 1-type, whereas others possess beta-adrenoceptor stimulant activity (partial agonism). The clinical importance of these latter properties remains controversial. The selectivity for beta 1-adrenoceptors, which can be demonstrated pharmacologically for atenolol, metoprolol, and practolol, appears quite broad. Nevertheless a clear advantage over nonselective compounds with respect to their effects on lung function and vascular resistance in patients has not been established. There are two possible explanations. The first is that the doses used therapeutically may lie outside the selective range; the second is that most tissues appear to possess and mixed population of beta 1- and beta 2-adrenoceptors. According to our present understanding, even absolute specificity for a given subtype cannot provide organ or tissue specificity. Partial agonists provide a constant stimulation of beta-adrenoceptors while at the same time preventing access of catecholamines to the receptor they occupy. With some compounds (e.g., pindolol), stimulant activity may be sufficient to counterbalance the myocardial depression normally resulting from blockade of basal sympathetic tone. Heart rate and cardiac output are thus maintained within normal limits and compensatory increases in vasomotor tone (seen with antagonists lacking intrinsic activity) do not occur. Pindolol has been shown to dilate blood vessels at very low doses and to produce significant relaxation of isolated tracheal smooth muscle at concentrations within the range of therapeutic plasma levels found in humans. These effects may underly the relatively low incidence of bronchopulmonary and vascular side effects reported for this compound.

The beta-adrenergic blocking agents and the treatment of glaucoma

The autonomic nervous system is divided into the parasympathetic and sympathetic systems, with three types of adrenergic receptors: alpha (smooth muscle contraction), beta1 (cardiac acceleration and fatty acid mobilization) and beta2 (smooth muscle relaxation). Substances affecting the function of the adrenergic system are the agonists or stimulators, which mimic the effects of endogenous norepinephrine or epinephrine, and antagonists or blockers, which block the receptors and prevent stimulation by the agonists. Autonomic stimulation in the eye mediates various changes which apparently affect outflow facility and rate of formation of aqueous humor. Alteration of either or both of these factors by autonomic agonists or antagonists may have a direct or an indirect effect on intraocular pressure. Beta-adrenergic blocking substances have been used to treat a variety of diseases. Some of the effects of these drugs are attributable to properties other than beta blockade, such as intrinsic sympathomimetic activity and local anaesthetic activity. Side effects of this class of drugs require caution in cases of congestive heart failure and in asthmatics. Autonomic agents used in the treatment of ocular hypertension and glaucoma include pilocarpine, a chilinergic agonist, epinephrine, an adrenergic agonist, and various beta adrenergic blockers or antagonists including propranolol, atenolol and timolol. The physico-chemical properties and pharmacokinetics of timolol are reviewed. Data showing a significant reduction in intraocular pressure as a result of ocular instillation of timolol are presented. Reduction of the rate of aqueous formation appears to be the mechanism of action. A low incidence of non-serious side effects is reported.