OBJECT DRUGS

Cholinesterase Inhibitors:

• Donepezil (Aricept, etc.)
• Galantamine (Razadyne, etc.)
• Rivastigmine (Exelon)

PRECIPITANT DRUGS

Beta-Blockers:

• Acebutolol (Sectral)
• Atenolol (Tenormin)
• Betaxolol (Kerlone, etc.)
• Bisoprolol (Zebeta)
• Carteolol (Ocupress)
• Carvedilol (Coreg, etc.)
• Esmolol (Brevibloc)
• Labetalol (Trandate)
• Levobunolol (Betagan, etc.)
• Metoprolol (Lopressor, etc.)
• Nadolol (Corgard)
• Nebivolol (Bystolic)
• Penbutolol (Levatol)
• Pindolol (Visken)
• Propranolol (Inderal, etc.)
• Sotalol (Betapace, etc.)
• Timolol (Blocadren, etc.)

Comment:

Cholinesterase inhibitors increase vagal tone, which tends to slow the heart rate. When they are given with other drugs that slow heart rate such as beta-blockers, excessive bradycardia can result. In some cases the combination of cholinesterase inhibitors and bradycardic drugs has been associated with life-threatening reactions, with severe bradycardia, cardiac arrhythmias, and even cardiac arrest. More study is needed to establish the incidence and magnitude of these interactions, but the potential severity of the reactions dictates that the combinations should be used only with close monitoring.

Class 2: Use Only if Benefit Felt to Outweigh Risk

• Consider Alternative: If appropriate for the patient, consider using an alternative to the cholinesterase inhibitor or the beta blocker.

Circumvent/Minimize: In some cases of excessive bradycardia due to cholinesterase inhibitor drug interactions, a cardiac pacemaker has been inserted and the drugs continued.

• Monitor: If the combination is used, monitor the heart rate for excessive slowing, and be alert for other adverse effects such as hypotension and fainting.