Can bystolic cause depression

Q I take Bystolic for blood pressure and was instructed to take it in the morning. The side effects leave me feeling washed out, drowsy and listless all day. Since blood pressure is lower during sleep and rises slowly near morning, I think it would be better to take the medication at bedtime, when the side effects would occur and help me sleep. Also, Bystolic reaches peak plasma levels in 1 1/2 to 4 hours, so taking it at night would be ideal to control blood pressure when it begins to rise. Is this a good strategy?

A You are right that blood pressure varies during the day, and also that the concentration of medication in blood varies after you take it. It makes perfect sense to try to match the need for the medication to its supply. Unfortunately, it’s not always so easy.

For example, with the beta blocker nebivolol (Bystolic) you mention, if you wanted peak levels to correlate with peak effect, you would need to take the medication around 3 or 4 a.m.

I understand why you want to take it at night, but then the peak blood pressure effect of the medicine would be when you least need it.

On the other hand, the peak side effects may be happening when you don’t notice them.

I think it’s worth a trial. See how your blood pressure is after taking it at night, compared with taking it in the morning. Also note how bad the side effects are.

If the side effects are still so severe, talk to your doctor about changing to a different medicine. There are so many blood pressure medicines available that you are likely to find one that works without causing you problems. Nebivolol is a good medicine for many people, but it may not be the right one for you.

Q I am very concerned about my grandchild’s growth. She is 6 years old and has not grown at all this past year. She is 42 inches tall and weighs 40 pounds. She is the smallest child in her first-grade class. During school activities, I’ve noticed some of the 3- and 4-year-old siblings of her classmates are taller than she. This doesn’t seem to concern her parents, and her mom is an RN. Am I overreacting?

A Not growing in a year is not normal. If that’s true, her pediatrician should be looking for any conditions — there are many — that can cause a child to stop growing.

In days past, if a child didn’t have a reason to not be growing or was growing at a slower rate than normal, we were unable to do anything about it. Now that human growth hormone (HGH) is available for children who are short, parents have a choice of whether to use this medication to make their children taller.

The medication is FDA-approved for children in the shortest 1 percent of their age and in absence of other diseases. Your granddaughter is right around that level.

The real question is this: Will treatment with this medication make her happier or healthier? There certainly are costs — it is expensive, requires prolonged treatment and can rarely have side effects.

Although on average, a girl can expect about 2 inches of extra height after a full course of treatment, it’s not clear this makes everyone happier.

If being shorter than others isn’t bothering her or her parents, I wouldn’t recommend treatment with growth hormone. I think there are appropriate times to use this medication, but the decision isn’t easy, and it should be made considering all risks and benefits.

Send questions to Dr. Roach to [email protected]

Q I question whether a 75-year-old woman with atrial fibrillation who had a stroke last year should drink any alcoholic beverages. What about moderate alcohol use?

A Atrial fibrillation is an abnormal, chaotic rhythm of the atria, the top chambers of the heart.

Atrial fibrillation is a problem for several reasons, especially as it predisposes one to stroke. Because the atria don’t contract normally, blood clots tend to form inside the heart, and without treatment, about 5 percent of people with atrial fibrillation will have a stroke per year.

Treatment, most commonly with warfarin as an anticoagulant, reduces the stroke risk to about 1.4 percent per year.

Frequent heavy use of alcohol is probably — but not definitely — a risk for atrial fibrillation. Acute intoxication with alcohol is a risk for atrial fibrillation.

People who drink alcohol excessively also have difficulty with anticoagulation, because of associated diet abnormalities and alcohol’s direct toxic effect on the bone marrow.

For all of these reasons, excess alcohol certainly should be avoided by anyone with atrial fibrillation.

Since you ask specifically about moderate alcohol, I would recommend no more than one alcoholic drink per day. Remember that a 12-ounce glass of beer, a 5-ounce glass of wine and a 1 1/2-ounce hard alcohol drink all contain roughly the same amount of alcohol, and all are considered one drink.

Q Why do commercials for cholesterol-lowering medications have a goal of 100 for bad cholesterol? I thought it was 180. I heard a guest on a television show say that everyone older than 40 should be on a statin drug. True?

A Let me answer the second question first. Not everybody needs a statin drug, regardless of age. Statin drugs lower the risk for a heart attack in people who already have blockages in their heart. For people without proven heart disease but with a high risk of heart disease, statins also reduce the risk of heart attack.

However, since every drug has the possibility of side effects and can be expensive, it is important to use the medication only for people who are more likely to have benefit than a harm. This includes people with diabetes, with blockages in the arteries of the legs and with multiple risk factors, including high blood pressure, smoking and a strong family history of heart disease.

There is clear evidence some people with multiple risk factors and a low HDL cholesterol (the good kind) can reduce their risk for heart attack even with normal total cholesterol levels. Only by taking a full history and exam and looking at cholesterol numbers and perhaps other laboratory data can your doctor give you the information you need to decide whether to take a statin. Taking a statin drug is not the only way to lower your risk of heart disease — a healthy diet and regular exercise do that, too.

If a statin is recommended, the decision of how low to push the LDL cholesterol (the bad kind) is less controversial. The standard recommendation is an LDL level below 100, with less than 70 optional for people at high risk.

Q I am an 87-year-old male in very good health but with constipation. My doctor has prescribed Metamucil, which helps greatly. What causes this condition, and is there anything that is more effective? I have severe flatulence, which strikes at the worst possible times. Any suggestions?

A Constipation is very common, especially as we get older. Some causes of constipation include not getting enough fiber in one’s diet, not getting enough exercise and taking in inadequate fluids. Some prescription medications can cause constipation as well.

I agree with your doctor, because Metamucil is a fiber supplement. Unfortunately, flatulence is a normal side effect of fiber. Taking it every day does help the body get used to it and may reduce side effects, including gas and bloating.

You also can get fiber through foods, especially whole grains and vegetables.

Also, make sure you are keeping up your fluid intake and doing plenty of walking.

Send questions to Dr. Roach to [email protected]

BYSTOLIC—Flexible dosing and administration1

Important Safety Information

  • BYSTOLIC is contraindicated in patients with severe bradycardia, heart block greater than first degree, cardiogenic shock, decompensated cardiac failure, sick sinus syndrome (unless a permanent pacemaker is in place), severe hepatic impairment (Child-Pugh >B), and in patients who are hypersensitive to any component of this product.

Warnings and Precautions

  • Do not abruptly discontinue BYSTOLIC therapy in patients with coronary artery disease. Severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported following the abrupt discontinuation of therapy with beta blockers. Myocardial infarction and ventricular arrhythmias may occur with or without preceding exacerbation of the angina pectoris. Caution patients without overt coronary artery disease against interruption or abrupt discontinuation of therapy. As with other beta blockers, when discontinuation of BYSTOLIC is planned, carefully observe and advise patients to minimize physical activity. Taper BYSTOLIC over 1 to 2 weeks when possible. If the angina worsens or acute coronary insufficiency develops, restart BYSTOLIC promptly, at least temporarily.
  • BYSTOLIC was not studied in patients with angina pectoris or who had a recent MI.
  • In general, patients with bronchospastic diseases should not receive beta blockers.
  • Because beta blocker withdrawal has been associated with an increased risk of MI and chest pain, patients already on beta blockers should generally continue treatment throughout the perioperative period if undergoing major surgery. If BYSTOLIC is to be continued perioperatively, monitor patients closely when anesthetic agents which depress myocardial function, such as ether, cyclopropane, and trichloroethylene are used. If beta-blocking therapy is withdrawn prior to major surgery, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures.

The beta-blocking effects of BYSTOLIC can be reversed by beta agonists, eg, dobutamine or isoproterenol. However, such patients may be subject to protracted severe hypotension. Additionally, difficulty in restarting and maintaining the heartbeat has been reported with beta blockers.

  • Beta blockers may mask some of the manifestations of hypoglycemia, particularly tachycardia. Advise patients subject to spontaneous hypoglycemia and diabetic patients receiving insulin or oral hypoglycemic agents about these possibilities.
  • Beta blockers may mask clinical signs of hyperthyroidism, such as tachycardia. Abrupt withdrawal of beta blockers in these patients may be followed by an exacerbation of symptoms or may precipitate a thyroid storm.
  • Beta blockers can precipitate or aggravate symptoms of arterial insufficiency in patients with peripheral vascular disease.
  • Because of significant negative inotropic and chronotropic effects in patients treated with beta blockers and calcium channel blockers of the verapamil and diltiazem type, monitor the ECG and blood pressure of patients treated concomitantly with these agents.
  • When BYSTOLIC is co-administered with an inhibitor or an inducer of CYP2D6, monitor patients closely and adjust the nebivolol dose according to blood pressure response. The dose of BYSTOLIC may need to be reduced. When BYSTOLIC is administered with fluoxetine, significant increases in d-nebivolol may be observed (ie, an 8-fold increase in AUC and a 3-fold increase in Cmax for d‑nebivolol).
  • Renal clearance of nebivolol is decreased in patients with severe renal impairment. In patients with severe renal impairment (ClCr less than 30 mL/min) the recommended initial dose is 2.5 mg once daily; titrate up slowly if needed. BYSTOLIC has not been studied in patients receiving dialysis.
  • Metabolism of nebivolol is decreased in patients with moderate hepatic impairment. In patients with moderate hepatic impairment, the recommended initial dose is 2.5 mg once daily; titrate up slowly if needed. BYSTOLIC has not been studied in patients with severe hepatic impairment and therefore it is not recommended in that population.
  • Patients with a history of severe anaphylactic reactions to a variety of allergens may be more reactive to repeated challenge and may be unresponsive to the usual doses of epinephrine while taking beta blockers.
  • In patients with known or suspected pheochromocytoma, initiate an alpha blocker prior to the use of any beta blocker.

Adverse Reactions

Drug Interactions

  • Use caution when BYSTOLIC is co-administered with CYP2D6 inhibitors (quinidine, propafenone, fluoxetine, paroxetine, etc).
  • Do not use BYSTOLIC with other beta blockers.
  • Both digitalis glycosides and beta blockers slow atrioventricular conduction and decrease heart rate. Concomitant use can increase the risk of bradycardia.
  • BYSTOLIC can exacerbate the effects of myocardial depressants or inhibitors of AV conduction, such as certain calcium antagonists (particularly of the phenylalkylamine and benzothiazepine classes), or antiarrhythmic agents, such as disopyramide.

Use in Specific Populations

  • BYSTOLIC is not recommended during nursing.
  • In a placebo-controlled trial of 2128 patients (1067 BYSTOLIC, 1061 placebo) over 70 years of age with chronic heart failure receiving a maximum dose of 10 mg per day for a median of 20 months, no worsening of heart failure was reported with nebivolol compared to placebo. However, if heart failure worsens consider discontinuation of BYSTOLIC.

Please see full Prescribing Information.


How does this medication work? What will it do for me?

Nebivolol belongs to the class of medications called selective beta-blockers. It is used alone or with diuretics (water pills) or angiotensin converting enzyme (ACE) inhibitors to treat mild to moderately high blood pressure. It is believed to decrease blood pressure by relaxing the muscles surrounding the blood vessels allowing blood to flow more easily, reduce the heart rate and reduce the production of chemicals in the kidney that are responsible for causing increased blood pressure.

This medication may be available under multiple brand names and/or in several different forms. Any specific brand name of this medication may not be available in all of the forms or approved for all of the conditions discussed here. As well, some forms of this medication may not be used for all of the conditions discussed here.

Your doctor may have suggested this medication for conditions other than those listed in these drug information articles. If you have not discussed this with your doctor or are not sure why you are taking this medication, speak to your doctor. Do not stop taking this medication without consulting your doctor.

Do not give this medication to anyone else, even if they have the same symptoms as you do. It can be harmful for people to take this medication if their doctor has not prescribed it.

What form(s) does this medication come in?

2.5 mg
Each light blue, triangle-shaped, biconvex, unscored tablet engraved with “FL” on one side and “2.5” on the other contains 2.5 mg of nebivolol. Nonmedicinal ingredients: colloidal silicon dioxide, croscarmellose sodium, FD&C Blue No. 2 Lake, FD&C Yellow No. 6 Lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, pregelatinized starch, polysorbate 80, and sodium lauryl sulfate.

5 mg
Each beige, triangle-shaped, biconvex, unscored tablet engraved with “FL” on one side and “5” on the other contains 5 mg of nebivolol. Nonmedicinal ingredients: colloidal silicon dioxide, croscarmellose sodium, FD&C Blue No. 2 Lake, FD&C Yellow No. 6 Lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, pregelatinized starch, polysorbate 80, and sodium lauryl sulfate.

10 mg
Each pinkish-purple, triangle-shaped, biconvex, unscored tablet engraved with “FL” on one side and “10” on the other contains 10 mg of nebivolol. Nonmedicinal ingredients: colloidal silicon dioxide, croscarmellose sodium, D&C Red No. 27 Lake, FD&C Blue No. 2 Lake, FD&C Yellow No. 6 Lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, pregelatinized starch, polysorbate 80, and sodium lauryl sulfate.

20 mg
Each light blue, triangle-shaped, biconvex, unscored tablet engraved with “FL” on one side and “20” on the other contains 20 mg of nebivolol. Nonmedicinal ingredients: colloidal silicon dioxide, croscarmellose sodium, D&C Red No. 27 Lake, FD&C Blue No. 2 Lake, FD&C Yellow No. 6 Lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, pregelatinized starch, polysorbate 80, and sodium lauryl sulfate.

How should I use this medication?

The recommended starting dose for adults is 5 mg taken once daily. It should be taken at approximately the same time each day. If a higher dose is needed, your doctor may have you increase the dose slowly up to a maximum of 20 mg taken once daily.

Nebivolol may be taken with or without food.

Many things can affect the dose of medication that a person needs, such as body weight, other medical conditions, and other medications. If your doctor has recommended a dose different from the ones listed here, do not change the way that you are taking the medication without consulting your doctor.

It is important to take this medication exactly as prescribed by your doctor.

If you miss a dose, skip the missed dose and continue with your regular dosing schedule. Do not take a double dose to make up for a missed one. If you are not sure what to do after missing a dose, contact your doctor or pharmacist for advice.

Store this medication at room temperature, protect it from light and moisture, and keep it out of the reach of children.

Do not dispose of medications in wastewater (e.g. down the sink or in the toilet) or in household garbage. Ask your pharmacist how to dispose of medications that are no longer needed or have expired.

Who should NOT take this medication?

Do not use nebivolol if you:

  • are allergic to nebivolol or any ingredients of the medication
  • have a condition known as “sick sinus syndrome”
  • have a very slow heart rate
  • have worsening congestive heart failure
  • have serious heart block (second- or third-degree AV block)
  • have severe peripheral arterial disorders (blockage of blood flow to limbs of body)
  • have cardiogenic shock
  • have severely reduced liver function
  • have galactose, glucose-galactose or lactose intolerance

What side effects are possible with this medication?

Many medications can cause side effects. A side effect is an unwanted response to a medication when it is taken in normal doses. Side effects can be mild or severe, temporary or permanent.

The side effects listed below are not experienced by everyone who takes this medication. If you are concerned about side effects, discuss the risks and benefits of this medication with your doctor.

The following side effects have been reported by at least 1% of people taking this medication. Many of these side effects can be managed, and some may go away on their own over time.

Contact your doctor if you experience these side effects and they are severe or bothersome. Your pharmacist may be able to advise you on managing side effects.

  • cough
  • diarrhea
  • dizziness
  • dry mouth
  • fatigue
  • headache
  • joint or back pain
  • nausea
  • nasal congestion and throat irritation
  • rash
  • trouble sleeping
  • vision changes

Although most of the side effects listed below don’t happen very often, they could lead to serious problems if you do not seek medical attention.

Check with your doctor as soon as possible if any of the following side effects occur:

  • breathing difficulty
  • decreased heart rate
  • memory problems
  • severe dizziness or fainting
  • signs of heart problems (e.g., fast, irregular heartbeat or pulse, chest pain, difficulty breathing)
  • swelling in legs or feet
  • vision problems

Stop taking the medication and seek immediate medical attention if any of the following occur:

  • chest pain
  • signs of heart attack (e.g., sudden chest pain or pain radiating to back, down arm, jaw; sensation of fullness of the chest; nausea; vomiting; sweating; anxiety)
  • signs of a serious allergic reaction (e.g., abdominal cramps, difficulty breathing, nausea and vomiting, or swelling of the face and throat)

Some people may experience side effects other than those listed. Check with your doctor if you notice any symptom that worries you while you are taking this medication.

Are there any other precautions or warnings for this medication?

Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breast-feeding, and any other significant facts about your health. These factors may affect how you should use this medication.

Breathing conditions: In general, people who have asthma and certain other breathing problems or chronic lung disease should use nebivolol cautiously, as it can also have the effect of causing breathing difficulty. Low doses of nebivolol may be taken with caution by those with asthma who do not respond to or cannot tolerate alternative treatment. If you have breathing problems, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. It may be necessary to monitor your blood glucose levels more often when you are taking this medication.

Diabetes: As with other medications in this family, nebivolol makes the signs of low blood sugar less noticeable. If you have diabetes and take insulin or other medications that affect blood glucose levels, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. It may be necessary to monitor your blood glucose levels more often when you are taking this medication.

Dizziness/reduced alertness: Nebivolol may cause dizziness or lightheadedness, affecting your ability to concentrate well enough to drive or operate machinery. Avoid these and other hazardous tasks until you have determined how this medication affects you.

Hyperthyroidism: Nebivolol can reduce the symptoms that occur when you have hyperthyroidism (high levels of thyroid hormones). It does not affect the thyroid gland, it only hides the symptoms of an over-active thyroid gland. Stopping the medication suddenly could worsen this condition.

Kidney function: Kidney disease or reduced kidney function may cause this medication to build up in the body, causing side effects. If you have kidney problems, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Liver function: Liver disease or reduced liver function may cause this medication to build up in the body, causing side effects. If you have liver problems, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. Your doctor may want to test your liver function regularly with blood tests while you are taking this medication.

If you experience symptoms of liver problems such as fatigue, feeling unwell, loss of appetite, nausea, yellowing of the skin or whites of the eyes, dark urine, pale stools, abdominal pain or swelling, and itchy skin, contact your doctor immediately.

Pheochromocytoma: This medication can worsen the symptoms of pheochromocytoma (a tumour of the adrenal gland). If you have a pheochromocytoma, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Severe allergies: If you have allergies severe enough to cause anaphylaxis (a severe allergic reaction where swelling of the face, lips, and throat make it difficult to breathe), you should talk to your doctor about what to do if you have an allergic reaction. Nebivolol may make it more difficult to treat your allergic reaction with epinephrine.

Stopping the medication: Nebivolol should not be stopped suddenly. There have been reports of severe worsening of angina and of heart attack or abnormal heart rhythms occurring in people with angina pectoris who have done this. If it is necessary to stop taking this medication, your doctor will advise you how to gradually reduce your dose, to reduce the risk of these effects.

Pregnancy: The safety of this medication during pregnancy has not been determined. This medication should not be used during pregnancy unless the benefits outweigh the risks. If you become pregnant while taking this medication, contact your doctor immediately.

Breast-feeding: It is not known if nebivolol passes into breast milk. If you are a breast-feeding mother and are taking this medication, it may affect your baby. Talk to your doctor about whether you should continue breast-feeding.

Children: The safety and effectiveness of using this medication have not been established for children.

What other drugs could interact with this medication?

There may be an interaction between nebivolol and any of the following:

  • abiraterone
  • acetylcholinesterase inhibitors (e.g., donepezil, galantamine, rivastigmine)
  • aldesleukin
  • aliskiren
  • alpha/beta agonists (e.g., epinephrine, norepinephrine)
  • alpha blockers (e.g., alfuzosin, doxazosin, tamsulosin)
  • alpha agonists (e.g., clonidine, methyldopa)
  • amifostine
  • amiodarone
  • amphetamines (e.g., dextroamphetamine, methamphetamine)
  • angiotensin converting enzyme inhibitors (ACEIs; enalapril, ramipril)
  • angiotensin receptor blockers (ARBs; e.g., candesartan, irbesartan, losartan)
  • anti-malarials (e.g., chloroquine, hydroxychloroquine, primaquine)
  • anti-psychotics (e.g., chlorpromazine, clozapine, haloperidol, quetiapine)
  • barbiturates (e.g., butalbital, phenobarbital)
  • other beta-adrenergic blockers (e.g., atenolol, propranolol, sotalol)
  • bethanechol
  • brimonidine
  • bromocriptine
  • bupivacaine
  • bupropion
  • cabergoline
  • calcium channel blockers (e.g., amlodipine, diltiazem, nifedipine, verapamil)
  • celecoxib
  • chloroquine
  • cimetidine
  • cinacalcet
  • clobazam
  • clonidine
  • cocaine
  • darifenacin
  • delavirdine
  • dexamethasone
  • diazoxide
  • digoxin
  • diphenhydramine
  • dipyridamole
  • disopyramide
  • diuretics (water pills; e.g., furosemide, hydrochlorothiazide, triamterene)
  • dronedarone
  • ergot alkaloids (e.g., ergotamine, dihydroergotamine)
  • fentanyl
  • fingolimod
  • floctafenine
  • ginger
  • ginseng
  • grass pollen extract
  • guanfacine
  • insulin
  • isoniazid
  • ketoconazole
  • licorice
  • lidocaine
  • lopinavir
  • methacholine
  • methadone
  • methotrimeprazine
  • methylphenidate
  • minoxidil
  • mirabegron
  • monoamine oxidase inhibitors (MAOIs; e.g., moclobemide, phenelzine, selegiline, tranylcipromine)
  • nilotinib
  • nitrates (e.g., isosorbide dinitrate, isosorbide mononitrate)
  • nonsteroidal anti-inflammatories (NSAIDs; e.g., diclofenac, ibuprofen, naproxen)
  • octreotide
  • pasireotide
  • peginterferon alfa-2b
  • pentoxifylline
  • phosphodiesterase 5 inhibitors (e.g., sildenafil, tadalafil, vardenafil)
  • pilocarpine
  • prochlorperazine
  • propafenone
  • protein kinase inhibitors (e.g., ceritinib, crizotinib, imatinib, regorafenib)
  • quinidine
  • quinine
  • rifabutin
  • rifampin
  • ritonavir
  • rituximab
  • salmeterol
  • selective serotonin reuptake inhibitors (SSRIs; e.g., citalopram, fluoxetine, paroxetine, sertraline)
  • sulfonylureas (e.g., chlorpropamide, glyburide)
  • terbinafine
  • ticlopidine
  • tizanidine
  • theophyllines (e.g., aminophylline, oxtriphylline, theophylline)
  • thioridazine
  • tipranavir
  • tricyclic antidepressants (e.g., amitriptyline, clomipramine, desipramine, trimipramine)
  • yohimbine

If you are taking any of these medications, speak with your doctor or pharmacist. Depending on your specific circumstances, your doctor may want you to:

  • stop taking one of the medications,
  • change one of the medications to another,
  • change how you are taking one or both of the medications, or
  • leave everything as is.

An interaction between two medications does not always mean that you must stop taking one of them. Speak to your doctor about how any drug interactions are being managed or should be managed.

Medications other than those listed above may interact with this medication. Tell your doctor or prescriber about all prescription, over-the-counter (non-prescription), and herbal medications you are taking. Also tell them about any supplements you take. Since caffeine, alcohol, the nicotine from cigarettes, or street drugs can affect the action of many medications, you should let your prescriber know if you use them.

All material copyright MediResource Inc. 1996 – 2020. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source:

Dr. Holmberg is a freelance clinical writer based in Phoenix, Arizona.

Forest Laboratories’ and Mylan’s Bystolic

A new beta-blocker-Bystolic (nebivolol) by Forest Laboratories Inc and Mylan Inc-has been approved by the FDA. It is indicated for the treatment of hypertension in adults. Bystolic offers once-daily dosing that can be used either alone or in combination with other antihypertensive regimens.1

Often called the “silent killer,” hypertension usually presents without symptoms, and patients may not be diagnosed until damage has occurred to the heart, brain, eyes, or kidneys.2 Of the 72 million Americans who are affected by hypertension, about 65% of those diagnosed have not reached optimal blood pressure control.1,2

Mechanism of Action

Bystolic is a b-adrenergic receptor blocker. At doses less than 10 mg and in patients who are extensive metabolizers (most of the population), Bystolic displays b1 selective activity. In patients who are poor metabolizers and in doses greater than 10 mg, Bystolic has been shown to inhibit both b1 and b2 receptors. Bystolic does not affect the a1 adrenergic receptors when administered at clinically appropriate doses.3


The recommended starting dose for Bystolic is 5 mg once a day, with dose increases at 2-week intervals as appropriate to obtain optimal blood pressure control. The maximum daily dose is 40 mg.3

Clinical Trials

Three randomized, double-blind, multicenter, placebo-controlled trials have evaluated the effectiveness of Bystolic’s antihypertensive effects when administered as monotherapy. A total of 2016 patients (1811 given Bystolic; 205 given placebo) were given doses ranging from 1.25 mg daily to 40 mg daily and were followed for 12 weeks.3

A fourth placebo-controlled trial of 669 patients evaluated Bystolic in combination with up to 2 other antihypertensive agents from the following classes: angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, or thiazide diuretics. Bystolic doses ranged from 5 to 20 mg daily.3 An increasing response was noted in most studies at doses above 5 mg. Statistically significant reductions in both diastolic and systolic blood pressure were noticed in all groups at doses of 20 mg daily and higher.3

Contraindications, Warnings, and Precautions

Bystolic is contraindicated in patients with the following conditions: severe bradycardia, heart block greater than first degree, cardiogenic shock, decompensated cardiac failure, sick sinus syndrome without a permanent pacemaker in place, severe hepatic impairment, and hypersensitivity to any of its components.3

Bystolic should be used cautiously in patients with peripheral vascular disease, thyrotoxicosis, severe renal impairment, hepatic impairment of any extent, and in patients undergoing major surgery.

Concomitant treatment of Bystolic and nondihydropyridine calcium channel blockers should be avoided or used cautiously if necessary; in these cases, electrocardiogram and blood pressure should be monitored closely.

Patients with diabetes should be aware that treatment with beta-blockers may mask some of the signs and symptoms of hypoglycemia, such as tachycardia. Patients with bronchospastic disease should not receive beta-blockers.1

Drugs known to inhibit CYP2D6 may increase plasma levels of Bystolic; patients using these agents together should be monitored as appropriate.3

Prior to discontinuing treatment with Bystolic, the dose should be gradually reduced over 1 to 2 weeks. Sudden discontinuation of therapy has been associated with severe angina exacerbations, myocardial infarction, and ventricular arrhythmia.1

Bystolic is available in over 50 countries outside of North America.1 Bystolic is a pregnancy category C. Its use is not recommended in patients who are breast-feeding. Bystolic has not been studied in children younger than 18 years of age.3

Adverse Effects

The most commonly reported side effects from treatment with Bystolic included headache, fatigue, dizziness, diarrhea, nausea, insomnia, chest pain, bradycardia, dyspnea, rash, and peripheral edema.1

High blood pressure can lead to dangerous conditions like heart attack and stroke, so it’s important to keep it under control. Unfortunately, treatments like brand-only Bystolic (nebivolol) can be expensive—a monthly supply can cost well beyond $150 without insurance. What’s more, some commercial plans require patients to get a prior authorization and/or go through step therapy to be covered for Bystolic.

But there is good news—there are multiple ways for you to reduce your out-of-pocket cost.

How much does Bystolic cost?

As of July 2018, the cash price of Bystolic is around $160 for 30 tablets. GoodRx discounts can help reduce this price a bit—to about $140—but that’s still way too much for most people.

When will generic Bystolic be available?

Unfortunately, there is no generic Bystolic available, and we won’t see one for some years. Some predict that generic Bystolic may not be available until September 2021.

Even though we may have to wait many years to see a generic, there are other ways to save on Bystolic.

Savings Tip #1: Use your insurance, or ask your doctor to submit an appeal

The best way to save on brand-name drugs is by using your insurance, but sometimes that doesn’t work. Recently, more people have been on the hook for the high cost of these drugs because of high deductibles or plans dropping certain drugs from their formulary.

If you have insurance and your plan doesn’t cover Bystolic, ask your doctor about submitting an appeal. The exact process will depend on your insurer but often requires that you work with your doctor to submit a letter of appeal. If you have insurance, call your provider and ask how to get this process started.

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Savings Tip #2: Pay only $35 with the Bystolic savings card

You may be able to use a manufacturer coupon for Bystolic to save on your out-of-pocket costs. Here’s what you need to know about Bystolic’s manufacturer discount program:

Bystolic Savings Card

Program website
Phone number 1-800-572-5252
Manufacturer Allergan
How much can I save? Your copay may be reduced to as little as $35 per fill depending on your coverage.
How do I get the discount? Download and print a card online.
Are there any restrictions? This discount is only available for commercially insured patients.

Savings Tip #3: Apply for a patient assistance program

The Allergan Patient Assistance Program can help uninsured patients afford their medications. Here’s what you need to know:

Allergan US Patient Assistance Program

Program website
Phone number 1-800-851-0758
Manufacturer Allergan
How much can I save? If you are approved, your medication will be shipped to your doctor or pharmacy every 90 days at no cost to you.
How do I get the discount? Ask your doctor to help you submit an application. You can find the form on the program website or request one by calling 1-800-851-0758.
Are there any restrictions? You will need a valid prescription and proof of your gross monthly household income. Contact the program to see if you are eligible.

Savings Tip #4: Speak to your doctor about prescription workarounds

If none of the above options work for you, speak with your doctor about ways to save. Your doctor may talk to you about getting a prescription for a higher-dose pill (which you can cut in half to save on cost), filling a 90-day supply (which can be cheaper than a 30-day supply), or getting free samples.

Savings Tip #5: Ask your doctor about Bystolic alternatives

For those without insurance or adequate coverage, Bystolic can be too expensive.

Fortunately, there are multiple generic beta blockers on the market today that work similarly to Bystolic to treat high blood pressure. Metoprolol and carvedilol are two cost-effective generic options—a 30-day supply of metoprolol costs around $15, while a 30-day supply of carvedilol costs around $50. In fact, there is no evidence that Bystolic is better than these two generics, so they may be worth speaking with your doctor about.

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