The Skeptical Cardiologist

Nebivolol (Bystolic), the uniquely well-tolerated beta-blocker, is now available as a cheap generic

There is good news for those patients taking the beta-blocker drug Bystolic: it is now available as a generic (nebivolol) at a substantially lower price. Given nebivolol’s uniquely low side effect profile, many patients suffering beta-blocker side effects (fatigue, erectile dysfunction, shortness of breath, weight gain) may benefit from switching to it now without concern about high costs.

A patient alerted me to this development and shared with me his pharmacy summaries of the generic versus brand name costs of the drug.

Brand name Bystolic $62 for 30
generic nebivolol $10 for 30

My patient also noted that AbbVie (ABBV) the current maker of Bystolic has already started lowering the price and offering coupons, presumably due to the generic competition. Previously he would pay $200 for 30 Bystolic tablets. His nebivolol is coming from ANI pharmaceuticals whose website mentions that Bystolic” has a current annual U.S. market of about $1.05B.

Beta-blockers are used frequently in cardiology for abnormal cardiac rhythms (atrial fibrillation, PVCs, PACs, ventricular tachycardia) angina, heart failure and hypertension. Although nebivolol showed some promise in the treatment of heart failure it did not achieve an indication for that diagnosis.

Here is a 2017 chart of the most popular beta-blockers. The top 9 with the exception of Bystolic are all generic and therefore relatively inexpensive. Toprol XL is the brand name version of the long-acting, once-daily version of metoprolol but since there are generic versions of this drug (Metoprolol Succinate) I use those rather than Toprol XL.

Why Bystolic Is Important

There is much I can say about Bystolic. I’ll save specific discussion on its pharmacology and history for a subsequent post. Full disclosure: prior to becoming the skeptical cardiologist and eliminating pharmaceutical rep interactions in order to eliminate the bias such interactions create, I gave paid talks in 2008 for Forest Pharmaceutical on the drug when it was first released. Like all drug company speakers I spent a weekend receiving indoctrination into the wonders of the drug and I was paid handsomely to convey those wonders to physicians who were often eating free steaks while I spoke.

I am not proud of that work and I now scrupulously avoid sources of bias. Heretofore I avoided writing about Bystolic (because of concerns that lingering pharma influence would taint my opinions) but with a decade of experience with the drug and now that a generic is available I think it is important that doctors and physicians recognize its benefits within the family of beta-adrenergic blocking medications.

I’ve successfully switched lots of patients who were having side effects on other beta-blockers to Bystolic. I take the drug myself and it has worked well without any side effects for my hypertension and my hypertrophic cardiomyopathy (more on that also in a subsequent post.)

Here’s a summary description of the drug from the introduction to a recent Korean observational study (which showed it works as well in an Asian population as a white one)

Nebivolol is a third-generation vasodilatory β1-adrenergic receptor antagonist, which induces nitric oxide-mediated vasodilatory effects via β3 receptor agonism. Nebivolol has been shown to have similar or better treatment response and BP control compared with other antihypertensives or their combinations, with significantly better tolerability. Nebivolol was also effective in reducing SBP and DBP in patients with hypertension as an add-on to or as a fixed-dose combination with other antihypertensive agents Furthermore, in patients with hypertension with comorbidities, nebivolol has been reported to be lipid neutral, did not produce detrimental metabolic effects, and demonstrated a potentially positive effect on HDL

A few years ago I described another approach to consider in the patient with beta-blocker side effects: stopping beta-blockers altogether. I wrote a post (Is an unneeded beta-blocker making you feel logy?) several years ago about a patient who had undergone stenting of a coronary artery after presenting with chest pain diagnosed as a heart attack (non ST elevation MI or NSTEMI) a year earlier.

He was put on the beta-blocker carvedilol (brand name Coreg) and ever since then he had felt “logy”, his term for fatigue or lack of energy. After reviewing the literature I concluded that I could safely remove post-MI patients like him from beta-blockers if their left ventricular function was normal. A session at the recent AHA conference was devoted to discussing this same issue.

A meta-analysis of nebivolol trials from 20018 concluded:

 This meta-analysis showed that nebivolol 5 mg achieved similar or better rates of treatment response and BP normalization than other drug classes and other antihypertensive drugs combined, with similar tolerability to placebo and significantly better tolerability than losartan, CCAs, other beta-blockers, and all antihypertensive drugs combined. Although not definitive, this meta-analysis suggests that nebivolol 5 mg is likely to have advantages over existing antihypertensives and may have a role in the first-line treatment of hypertension.

Whether nebivolol should be a first-line agent for hypertension is debatable but any patient who requires a beta-blocker for cardiac conditions other than heart failure or hypertension, I will now consider it as my first choice, especially in patients who have underlying lung disease/bronchospasm, peripheral vascular disease, erectile dysfunction, or fatigue.

Antiadrenergically Yours,


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