Should Patients With Asthma Receive Beta-Blockers for Heart Problems?

Darrell T. Hulisz, PharmD

Disclosures

January 31, 2008

Question
I have encountered many patients with asthma who are being treated with cardioselective beta-blockers for various indications such as hypertension or heart failure. Given the risk for bronchospasm associated with beta-blockers, should these patients be taking this medication?

Response from Darrell T. Hulisz, PharmD
Associate Professor, Department of Family Medicine, Case Western Reserve University School of Medicine, University Hospitals, Case Medical Center, Cleveland, Ohio

The question of whether to alter beta-blocker therapy in patients with asthma has been reviewed extensively in the medical literature.[1,2,3,4,5] Cardioselective (beta-1) beta-blockers are efficacious in the treatment of heart failure, hypertension, tachyarrhythmias, and post-myocardial infarction. However, concerns about nonselective agents such as propranolol inducing bronchospasm emerged in older case reports.[6] Some consensus reports have even advised against the use of nonselective beta-blockers, including ophthalmic formulations, in patients with asthma.[3] However, these reports do allow for patients with mild to moderate disease to be treated with a cardioselective beta-blocker, if necessary.

The decision to recommend discontinuing a beta-blocker or substituting one beta-blocker for another in a patient with asthma is multifactorial. If the patient's asthma is well controlled and he or she is receiving a cardioselective beta-blocker, it seems prudent to leave well enough alone.

The available evidence supports the position that beta-blockers should not be withheld from patients with asthma who are under good control and who have comorbid diseases where beta-blockers have been proven to reduce mortality.[1,2,3,4,5] A Cochrane review of 19 studies found that beta-blockers did not adversely affect respiratory function in the short term.[1] Long-term data are not as readily available. This information was also examined in a meta-analysis.[2]

It is important to consider that some of the studies included patients who were younger than those normally treated with beta-blockers. Dose is also a factor, as cardioselective beta-blockers lose their selectivity as the dose increases (raising the risk for bronchospasm). Most available data supporting the safety of beta-blockers in reactive lung disease relate to patients with mild to moderate disease.

In conclusion, beta-blockers should not be stopped in patients with reactive airway disease that is well controlled and who have comorbid cardiovascular diseases.[1,2,3,4,5] Careful monitoring of respiratory function is necessary, with cautious increases of dosage, especially if increased dosage is necessary for stabilizing a comorbid condition.[3] The overall mortality benefit in heart failure, myocardial infarction, arrhythmias, and hypertension outweighs the risk of beta-blocker therapy. That being said, when starting a new medication to treat a disease state such as hypertension, nonselective beta-blockers may not be the first choice for patients with asthma if other alternatives are available that also significantly reduce mortality. However, some disease states such as post-myocardial infarction may not offer an alternative to beta-blockers.[4,5]

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