Elevated intraocular pressure: Ophthalmic:
Open-angle glaucoma or ocular hypertension:
Gel-forming solution: Instill 1 drop (either 0.25% or 0.5% solution) once daily.
Solution:
Istalol: Instill 1 drop (0.5% solution) once daily in the morning.
All other timolol solutions: Initial: Instill 1 drop (0.25% solution) into affected eye(s) twice daily; if response is not adequate, increase to 1 drop (0.5% solution) twice daily. May decrease dose to 1 drop once daily if intraocular pressure (IOP) is well controlled.
Angle-closure glaucoma, acute (off-label use): Instill 1 drop (0.5%) into the affected eye as part of a 4-drug regimen; may repeat in 30 to 60 minutes if IOP remains elevated (eg, >40 mm Hg). Note: Reserve medical management for emergency situations when an assessment by an ophthalmologist will be delayed by ≥1 hour (Pokhrel 2007).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Timolol (ophthalmic): Pediatric drug information")
Glaucoma: Infants, Children, and Adolescents: Use lowest effective dose; the gel formulation may be preferable due to decreased systemic absorption (Coppens 2009): Ophthalmic:
Gel-forming solution (Timolol GFS, Timoptic-XE): Instill 1 drop (either 0.25% or 0.5%) once daily into affected eye(s) (Coppens 2009; Moore 2007)
Solution (timolol maleate): Limited data available: Initial: 0.25% solution, instill 1 drop twice daily into affected eye(s); increase to 0.5% solution if response not adequate; decrease to 1 drop once daily into affected eye(s) if controlled; maximum dose: 1 drop (0.5% solution)/dose (Hoskins 1985; Moore 2007)
Infantile hemangioma, superficial: Limited data available: Infants and Children: Topical: Gel-forming solution: Apply 1 drop of the 0.5% gel-forming solution twice daily to the site (Chakkittakandiyil 2012; Chan 2013; Chen 2013; Lee 2013; Pope 2010). The largest experience is a multicenter retrospective report describing use in over 60 patients which showed improvement in all but one patient with a mean duration of treatment of 3.4 ± 2.7 months (Chakkittakandiyil 2012). A smaller, randomized trial compared timolol 0.5% gel (n=15) to placebo (n=17) on superficial infantile lesions covering various areas of the body; initial lesion improvements were observed after 12 to 16 weeks, and significant color changes reported at week 24 (Chan 2013). A smaller (n=13) retrospective, open-label trial also showed success with two drops of 0.25% timolol gel-forming solution twice daily on periocular infantile hemangiomas (Chambers 2012). Timolol was reported as being well tolerated in the trials.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Gel Forming Solution, Ophthalmic, as maleate [strength expressed as base]:
Timoptic-XE: 0.25% (5 mL) [contains tromethamine]
Timoptic-XE: 0.5% (5 mL)
Generic: 0.25% (5 mL); 0.5% (5 mL)
Solution, Ophthalmic, as hemihydrate [strength expressed as base]:
Betimol: 0.25% (5 mL); 0.5% (5 mL, 10 mL, 15 mL) [contains benzalkonium chloride]
Solution, Ophthalmic, as maleate [strength expressed as base]:
Istalol: 0.5% (2.5 mL, 5 mL) [contains benzalkonium chloride]
Timoptic: 0.25% (5 mL); 0.5% (5 mL, 10 mL) [contains benzalkonium chloride]
Generic: 0.25% (5 mL, 10 mL, 15 mL); 0.5% (2.5 mL, 5 mL, 10 mL, 15 mL)
Solution, Ophthalmic, as maleate [strength expressed as base, preservative free]:
Timolol Maleate Ocudose: 0.5% (60 ea)
Timoptic Ocudose: 0.25% (60 ea); 0.5% (60 ea)
Generic: 0.25% (60 ea); 0.5% (60 ea)
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Gel Forming Solution, Ophthalmic, as maleate [strength expressed as base]:
Timolol Maleate-EX: 0.25% (5 mL); 0.5% (5 mL) [contains polysorbate 80]
Timoptic-XE: 0.25% ([DSC]); 0.5% (5 mL)
Solution, Ophthalmic, as maleate [strength expressed as base]:
Timoptic: 0.5% (5 mL, 10 mL) [contains benzalkonium chloride]
Generic: 0.25% (5 mL, 10 mL); 0.5% (5 mL, 10 mL)
Ophthalmic: For topical ophthalmic use only. Wash hands before use; invert closed bottle and shake gel-forming solutions once before use. Remove contact lenses prior to administration; wait 15 minutes before reinserting if using products containing benzalkonium chloride. In most cases, separate administration of other ophthalmic agents by at least 5 to 10 minutes. When treating acute angle-closure glaucoma, separate administration of other ophthalmic agents by ≥1 minute (Pokhrel 2007).
Ophthalmic: Administer other topically applied ophthalmic medications at least 10 minutes prior to timolol.
Wash hands before use; invert closed bottle and shake gel once before use; remove cap carefully so that tip does not touch anything; hold bottle between thumb and index finger; use index finger of other hand to pull down the lower eyelid to form a pocket for the eye drop and tilt head back; place the dispenser tip close to the eye and gently squeeze the bottle to administer 1 drop; remove pressure on bottle after a single drop has been released; do not allow the dispenser tip to touch the eye; replace cap and store bottle in an upright position in a clean area; do not enlarge hole of dispenser; do not wash tip with water, soap, or any other cleaner. Some solutions contain benzalkonium chloride; wait at least 15 minutes after instilling solution before inserting soft contact lenses. With solution, apply gentle pressure to lacrimal sac during and immediately following instillation (1 minute) or instruct patient to gently close eyelid after administration, to decrease systemic absorption of ophthalmic drops (Urtti 1993; Zimmerman 1984).
Topical: Infantile Hemangioma: Wash hands. Apply drop to hemangioma site area and rub in gently to cover entire hemangioma (Chambers 2012; Chan 2013; Wu 2018).
Elevated intraocular pressure: Treatment of elevated intraocular pressure (IOP) in patients with ocular hypertension or open-angle glaucoma (manufacturer's labeling) or as part of a 4-drug medical management regimen in acute angle-closure glaucoma when the patient cannot be seen by an ophthalmologist for ≥1 hour (off-label use) (Pokhrel 2007).
Timolol may be confused with atenolol, Tylenol
Timoptic may be confused with Betoptic S, Talacen, Viroptic
Bottle cap color change: Timoptic: Both the 0.25% and 0.5% strengths are now packaged in bottles with yellow caps; previously, the color of the cap on the product corresponded to different strengths.
Betimol [US] may be confused with Betanol brand name for metipranolol [Monaco]
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%: Ophthalmic: Burning sensation of eyes, stinging of eyes
Frequency not defined:
Cardiovascular: Angina pectoris, bradycardia, cardiac arrhythmia, cardiac failure, cerebral ischemia, cerebrovascular accident, claudication, cold extremities, edema, heart block, hypertension, hypotension, palpitations, Raynaud's phenomenon
Central nervous system: Amnesia, anxiety, confusion, depression, disorientation, dizziness, drowsiness, exacerbation of myasthenia gravis, hallucination, headache, insomnia, nervousness, nightmares, paresthesia
Dermatologic: Alopecia, exacerbation of psoriasis, pemphigoid-like lesion, psoriasiform eruption, skin rash, urticaria
Endocrine & metabolic: Hypoglycemia (masked), decreased libido
Gastrointestinal: Anorexia, diarrhea, dyspepsia, nausea, xerostomia
Genitourinary: Impotence, Peyronie's disease, retroperitoneal fibrosis
Hypersensitivity: Angioedema, hypersensitivity reaction
Neuromuscular & skeletal: Systemic lupus erythematosus
Ophthalmic: Blepharitis, blepharoptosis, blurred vision, cataract, choroidal detachment (following filtration surgery), conjunctival injection, conjunctivitis, cystoid macular edema, decreased corneal sensitivity, decreased visual acuity, diplopia, eye discharge, eye pain, eye pruritus, foreign body sensation of eye, hyperemia, keratitis, lacrimation, visual disturbance (including refractive changes), xerophthalmia
Otic: Tinnitus
Respiratory: Bronchospasm, cough, dyspnea, nasal congestion, pulmonary edema, respiratory failure
Hypersensitivity to timolol or any component of the formulation; bronchial asthma or history of bronchial asthma; severe chronic obstructive pulmonary disease (COPD); sinus bradycardia; second- or third-degree atrioventricular block; overt heart failure; cardiogenic shock
Documentation of allergenic cross-reactivity for Ophthalmic Beta-Adrenergic Blocking Agents is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.
Concerns related to adverse events:
• Anaphylactic reactions: Use with caution in patients with history of atopy or a history of severe anaphylaxis to a variety of allergens; patients taking beta-blockers may become more sensitive to repeated challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects.
• Choroidal detachment: Beta-blockade and/or other aqueous suppressive therapy have been associated with choroidal detachment following filtration procedures.
Disease-related concerns:
• Cerebrovascular disease: Use with caution in cerebrovascular insufficiency; consider alternative therapy for patients with signs/symptoms of decreased cerebral blood flow after therapy initiation.
• Diabetes: Use with caution in patients with diabetes mellitus (especially labile diabetes); may potentiate hypoglycemia and/or mask signs and symptoms.
• Heart failure: Use with caution in patients with compensated heart failure and monitor for a worsening of the condition; may lead to heart failure in patients without a history of heart failure. Use is contraindicated in overt heart failure. In a scientific statement from the American Heart Association, timolol has been determined to be an agent that may exacerbate underlying myocardial dysfunction (magnitude: major) (AHA [Page 2016]).
• Myasthenia gravis: Use with caution in patients with myasthenia gravis; may worsen disease or other myasthenic symptoms (eg, diplopia, ptosis, and generalized weakness).
• Peripheral vascular disease (PVD) and Raynaud disease: Can precipitate or aggravate symptoms of arterial insufficiency in patients with PVD and Raynaud disease. Use with caution and monitor for progression of arterial obstruction.
• Respiratory disease: In general, patients with bronchospastic disease should not receive beta-blockers; if used at all, should be used cautiously with close monitoring. Severe respiratory reactions, including fatalities due to bronchospasm in patients with asthma, have been reported with ophthalmic use. Use is contraindicated in bronchial asthma or history of bronchial asthma and severe COPD.
• Thyroid disease: May mask signs of hyperthyroidism (eg, tachycardia). If thyrotoxicosis is suspected, carefully manage and monitor; abrupt withdrawal may exacerbate symptoms of hyperthyroidism or precipitate thyroid storm.
Special populations:
• Contact lens wearers: Some products may contain benzalkonium chloride, which may be absorbed by soft contact lenses; remove lens prior to administration and wait 15 minutes before reinserting.
Other warnings/precautions:
• Absorption: Systemic absorption of timolol and adverse effects may occur with ophthalmic use, including respiratory and cardiovascular effects (eg, bradycardia and/or hypotension). Beta-blocker therapy should not be withdrawn abruptly in order to avoid acute tachycardia, hypertension, and/or ischemia.
• Appropriate use: Should not be used alone in angle-closure glaucoma (has no effect on pupillary constriction). Concomitant use of 2 topical beta-blockers is not recommended. Multidose vials have been associated with development of bacterial keratitis; avoid contamination.
• Surgery: May block systemic effects of beta agonists (eg, epinephrine, norepinephrine); notify anesthesiologist if patient is receiving ophthalmic beta blocker therapy. Patients undergoing planned major surgery should be gradually tapered off therapy (if possible) prior to procedure. If necessary during surgery, effects of beta blocker therapy may be reversed by adrenergic agonists.
Pediatric patients, particularly infants, may attain higher plasma concentrations compared to adults (Coppens 2004; Passo 1984); systemic adverse effects may occur (eg, hypotension, bradycardia, bronchospasm, and apnea); use the lowest effective dose; some experts advocate avoiding the use of ophthalmic beta-blockers in premature and small infants (Moore 2007).
Systemic absorption has been reported following topical use of timolol ophthalmic products when used to treat infantile hemangiomas, which may lead to adverse events, such as hypothermia, hypotension, apnea, and bradycardia, particularly in patients with PMA <44 weeks, weight <2.5 kg, or those with a history of apnea, bradycardia, or chronic lung disease. In addition, use on or near mucosa, sites with thinner skin (eg, perineum), ulcerated hemangiomas, or sites under occlusion may enhance systemic absorption. Risk may be increased with higher doses (eg, >2 drops per day). The risk versus benefit must be weighed for each patient prior to use (AAP [Darrow 2015]; Frommelt 2016; McMahon 2012; Ng 2017; Püttgen 2016).
Substrate of CYP2D6 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Acetylcholinesterase Inhibitors: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy
Ajmaline: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy
Alpha1-Blockers: Beta-Blockers may enhance the orthostatic hypotensive effect of Alpha1-Blockers. The risk associated with ophthalmic products is probably less than systemic products. Risk C: Monitor therapy
Alpha2-Agonists: May enhance the AV-blocking effect of Beta-Blockers. Sinus node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound hypertensive effect of Alpha2-Agonists. This effect can occur when the Alpha2-Agonist is abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists are unavailable. Risk D: Consider therapy modification
Amiodarone: May enhance the bradycardic effect of Beta-Blockers. Possibly to the point of cardiac arrest. Amiodarone may increase the serum concentration of Beta-Blockers. Risk C: Monitor therapy
Antidiabetic Agents: Beta-Blockers (Nonselective) may enhance the hypoglycemic effect of Antidiabetic Agents. Beta-Blockers (Nonselective) may diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy
Antipsychotic Agents (Phenothiazines): May enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents (Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy
Artemether and Lumefantrine: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy
Beta2-Agonists: Beta-Blockers (Nonselective) may diminish the bronchodilatory effect of Beta2-Agonists. Risk X: Avoid combination
Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Risk C: Monitor therapy
Bupivacaine: Beta-Blockers may increase the serum concentration of Bupivacaine. Risk C: Monitor therapy
Cannabis: Beta-Blockers may enhance the adverse/toxic effect of Cannabis. Specifically, the risk of hypoglycemia may be increased. Risk C: Monitor therapy
Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Risk D: Consider therapy modification
Cholinergic Agonists: Beta-Blockers may enhance the adverse/toxic effect of Cholinergic Agonists. Of particular concern are the potential for cardiac conduction abnormalities and bronchoconstriction. Risk C: Monitor therapy
CYP2D6 Inhibitors (Strong): May increase the serum concentration of Timolol (Ophthalmic). Risk C: Monitor therapy
Dipyridamole: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy
Disopyramide: May enhance the bradycardic effect of Beta-Blockers. Beta-Blockers may enhance the negative inotropic effect of Disopyramide. Risk C: Monitor therapy
DOBUTamine: Beta-Blockers may diminish the therapeutic effect of DOBUTamine. Risk C: Monitor therapy
Dronedarone: May enhance the bradycardic effect of Beta-Blockers. Dronedarone may increase the serum concentration of Beta-Blockers. This likely applies only to those agents that are metabolized by CYP2D6. Management: Use lower initial beta-blocker doses; adequate tolerance of the combination, based on ECG findings, should be confirmed prior to any increase in beta-blocker dose. Increase monitoring for clinical response and adverse effects. Risk D: Consider therapy modification
EPHEDrine (Systemic): Beta-Blockers may diminish the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
EPINEPHrine (Nasal): Beta-Blockers (Nonselective) may enhance the hypertensive effect of EPINEPHrine (Nasal). Risk C: Monitor therapy
EPINEPHrine (Oral Inhalation): Beta-Blockers (Nonselective) may enhance the hypertensive effect of EPINEPHrine (Oral Inhalation). Risk C: Monitor therapy
Epinephrine (Racemic): Beta-Blockers (Nonselective) may enhance the hypertensive effect of Epinephrine (Racemic). Risk C: Monitor therapy
EPINEPHrine (Systemic): Beta-Blockers (Nonselective) may enhance the hypertensive effect of EPINEPHrine (Systemic). Risk C: Monitor therapy
Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates): Beta-Blockers may enhance the vasoconstricting effect of Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates). Risk C: Monitor therapy
Etilefrine: May enhance the bradycardic effect of Beta-Blockers. Beta-Blockers may diminish the therapeutic effect of Etilefrine. Risk C: Monitor therapy
Etofylline: Beta-Blockers may diminish the therapeutic effect of Etofylline. Risk X: Avoid combination
Fexinidazole: Bradycardia-Causing Agents may enhance the arrhythmogenic effect of Fexinidazole. Risk X: Avoid combination
Fingolimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Fingolimod. Management: Consult with the prescriber of any bradycardia-causing agent to see if the agent could be switched to an agent that does not cause bradycardia prior to initiating fingolimod. If combined, perform continuous ECG monitoring after the first fingolimod dose. Risk D: Consider therapy modification
Grass Pollen Allergen Extract (5 Grass Extract): Beta-Blockers may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). More specifically, Beta-Blockers may inhibit the ability to effectively treat severe allergic reactions to Grass Pollen Allergen Extract (5 Grass Extract) with epinephrine. Some other effects of epinephrine may be unaffected or even enhanced (e.g., vasoconstriction) during treatment with Beta-Blockers. Management: Consider alternatives to either grass pollen allergen extract (5 grass extract) or beta-blockers in patients with indications for both agents. Canadian product labeling specifically lists this combination as contraindicated. Risk D: Consider therapy modification
Insulins: Beta-Blockers (Nonselective) may enhance the hypoglycemic effect of Insulins. Beta-Blockers (Nonselective) may diminish the therapeutic effect of Insulins. Risk C: Monitor therapy
Isoproterenol: Beta-Blockers may diminish the therapeutic effect of Isoproterenol. Risk C: Monitor therapy
Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Risk C: Monitor therapy
Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Risk C: Monitor therapy
Lidocaine (Systemic): Beta-Blockers may increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Mavacamten: Beta-Blockers may enhance the adverse/toxic effect of Mavacamten. Specifically, negative inotropic effects may be increased. Risk C: Monitor therapy
Mepivacaine: Beta-Blockers may increase the serum concentration of Mepivacaine. Risk C: Monitor therapy
Methacholine: Beta-Blockers may enhance the adverse/toxic effect of Methacholine. Risk C: Monitor therapy
Methoxyflurane: May enhance the hypotensive effect of Beta-Blockers. Risk C: Monitor therapy
Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy
Mivacurium: Beta-Blockers may enhance the therapeutic effect of Mivacurium. Risk C: Monitor therapy
NIFEdipine: May enhance the hypotensive effect of Beta-Blockers. NIFEdipine may enhance the negative inotropic effect of Beta-Blockers. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May diminish the antihypertensive effect of Beta-Blockers. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents (Topical): May diminish the therapeutic effect of Beta-Blockers. Risk C: Monitor therapy
Ozanimod: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy
Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy
Ponesimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Ponesimod. Management: Avoid coadministration of ponesimod with drugs that may cause bradycardia when possible. If combined, monitor heart rate closely and consider obtaining a cardiology consult. Do not initiate ponesimod in patients on beta-blockers if HR is less than 55 bpm. Risk D: Consider therapy modification
Reserpine: May enhance the hypotensive effect of Beta-Blockers. Risk C: Monitor therapy
Rivastigmine: May enhance the bradycardic effect of Beta-Blockers. Risk X: Avoid combination
Siponimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia. If combined, consider obtaining a cardiology consult regarding patient monitoring. Risk D: Consider therapy modification
Succinylcholine: Beta-Blockers may enhance the neuromuscular-blocking effect of Succinylcholine. Risk C: Monitor therapy
Sulfonylureas: Beta-Blockers may enhance the hypoglycemic effect of Sulfonylureas. Cardioselective beta-blockers (eg, acebutolol, atenolol, metoprolol, and penbutolol) may be safer than nonselective beta-blockers. All beta-blockers appear to mask tachycardia as an initial symptom of hypoglycemia. Ophthalmic beta-blockers are probably associated with lower risk than systemic agents. Risk C: Monitor therapy
Sulfonylureas: Beta-Blockers (Nonselective) may enhance the hypoglycemic effect of Sulfonylureas. Beta-Blockers (Nonselective) may diminish the therapeutic effect of Sulfonylureas. Risk C: Monitor therapy
Tasimelteon: Beta-Blockers may diminish the therapeutic effect of Tasimelteon. Management: Consider avoiding nighttime administration of beta-blockers during tasimelteon therapy due to the potential for reduced tasimelteon efficacy. Risk D: Consider therapy modification
Theophylline Derivatives: Beta-Blockers (Nonselective) may diminish the bronchodilatory effect of Theophylline Derivatives. Risk C: Monitor therapy
Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy
White Birch Allergen Extract: Beta-Blockers may enhance the adverse/toxic effect of White Birch Allergen Extract. Specifically, beta-blockers may reduce the effectiveness of beta-agonists that may be required to treat systemic reactions to white birch allergen extract. Risk X: Avoid combination
Decreased fetal heart rate has been observed following maternal use of ophthalmic timolol during pregnancy (Wagenvoort 1998). Timolol is absorbed systemically following ophthalmic use; additional adverse effects observed with systemic administration may occur.
If ophthalmic agents are needed to treat glaucoma in pregnancy, the minimum effective dose should be used in combination with punctal occlusion to decrease exposure to the fetus (Johnson 2001; Salim 2014; Wagenvoort 1998).
Timolol is present in breast milk following ophthalmic administration.
Due to the potential for adverse events, breastfeeding infants (especially those with cardiorespiratory problems) should be monitored (Madadi 2008). The minimum effective dose should be used in combination with punctal occlusion to decrease potential exposure to the breastfeeding infant (Johnson 2001; Salim 2014; Samples 1988). Because of the potential for serious adverse reactions in the breastfeeding infant, the manufacturer recommends a decision be made whether to discontinue breastfeeding or to discontinue the drug, taking into account the importance of treatment to the mother.
Intraocular pressure (after ~4 weeks of therapy for chronic use; 30 to 60 minutes after acute administration for acute use [Pokhrel 2007]); monitor for systemic effect of beta-blockade with ophthalmic administration; blood pressure.
Blocks both beta-1 and beta-2 adrenergic receptors and reduces intraocular pressure by reducing aqueous humor production or possibly increasing the outflow of aqueous humor.
The exact mechanism of beta-blockers for infantile hemangiomas is unclear, but is hypothesized to be related to vasoconstriction, angiogenesis inhibition, growth factor inhibition, and induction of apoptosis (Bhat 2016).
Solution:
Onset of action: Intraocular pressure reduction: 30 minutes.
Peak effect: 1 to 2 hours.
Duration: 24 hours.
Absorption: Timolol is measurable in the serum following ophthalmic use. Timolol has been detected in the blood and urine of some infants who were treated topically for infantile hemangiomas (Weibel 2016).
Half-life elimination: 4 hours.
Solution (Betimol Ophthalmic)
0.25% (per mL): $33.12
0.5% (per mL): $35.12
Solution (Istalol Ophthalmic)
0.5% (per mL): $92.99
Solution (Timolol Maleate (Once-Daily) Ophthalmic)
0.5% (per mL): $64.47 - $70.19
Solution (Timolol Maleate Ophthalmic)
0.25% (per mL): $0.72 - $3.00
0.5% (per mL): $1.31 - $3.40
Solution (Timolol Maleate PF Ophthalmic)
0.25% (per each): $9.19
0.5% (per each): $9.10
Solution (Timoptic Ocudose Ophthalmic)
0.25% (per each): $9.96
0.5% (per each): $11.36
Solution (Timoptic Ophthalmic)
0.25% (per mL): $46.93
0.5% (per mL): $50.79
Solution get-forming (Timolol Maleate Ophthalmic)
0.25% (per mL): $37.57 - $48.56
0.5% (per mL): $43.45 - $53.22
Solution get-forming (Timoptic-XE Ophthalmic)
0.25% (per mL): $58.20
0.5% (per mL): $63.78
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