Recommendations for using beta-blockers in patients with COPD or asthma

Dispel fears about using beta-blockers in patients with COPD or asthma...
Abdelwahab Ward, BS Pharm, PharmD

Alerts still pop up when beta-blockers are used in patients with COPD or asthma, but these shouldn't always raise a red flag. Many of us were taught to avoid beta-blockers in these patients because of concerns about bronchoconstriction. But cardioSELECTIVE options (metoprolol [Seloken Zoc], bisoprolol [Concor], nebivolol [Nebilet], etc) don't cause more exacerbations or reduce airway function in COPD or asthma. And patients still respond to beta-agonists (salbutamol [Ventolin], salmeterol [Metrovent], etc). Plus, evidence continues to grow that beta-blockers in general may actually DECREASE exacerbations and improve survival in COPD patients, probably by treating coexisting CV disease.

  • Don't be concerned if COPD or asthma patients get a SELECTIVE beta-blocker especially in cases where they improve outcomes, such as after a heart attack or for heart failure with reduced ejection fraction (HFrEF).
  • Advise starting with a low dose and titrating up.
  • Continue to lean away from NONselective agents (carvedilol, propranolol, etc) in COPD, there's not much evidence of safety.
  • Recommend avoiding nonselective beta-blockers entirely in asthma. There's evidence bronchospasm or exacerbations can occur.
  • Be aware that even beta-blocker eye drops can result in significant blood levels and pose similar concerns in COPD or asthma. One drop of timolol 0.5% in each eye has about the same effect as 10 mg orally.
    • Consider betaxolol (Betoptic) if needed it's the only selective eye drop.
  • And educate patients to keep their eyes closed for at least one minute after instilling. This may limit absorption through tear ducts.

References

  1. Nielsen AO, Pedersen L, Sode BF, Dahl M. β-Blocker Therapy and Risk of Chronic Obstructive Pulmonary Disease - A Danish Nationwide Study of 1·3 Million Individuals. EClinicalMedicine. 2019 Jan 29;7:21-26.
  2. Rutten FH, Zuithoff NP, Hak E, Grobbee DE, Hoes AW. Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease. Arch Intern Med. 2010 May 24;170(10):880-7.
  3. Morales, D.R., Lipworth, et al. Respiratory effect of beta-blockers in people with asthma and cardiovascular disease: population-based nested case control study. BMC Medicine, 15(1).
Abdelwahab Ward, BS Pharm, PharmD