From the Guidelines
Beta blockers with high cardioselectivity, such as Betaxolol, are the most suitable option for patients with a history of bronchospasm. These medications primarily block beta-1 receptors in the heart while having less effect on beta-2 receptors in the lungs, reducing the risk of triggering bronchospasm 1. The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends the use of cardioselective beta blockers in patients with bronchospastic airway disease requiring a beta blocker 1.
Some key points to consider when prescribing beta blockers for patients with a history of bronchospasm include:
- Starting with a low dose and gradually titrating upward while monitoring for respiratory symptoms
- Close monitoring for wheezing, shortness of breath, or decreased peak flow measurements during initiation and dose adjustments
- Considering consultation with both a cardiologist and pulmonologist in cases of severe bronchospasm history to determine the optimal treatment approach
- Avoiding non-cardioselective beta blockers, such as Nadolol and Propranolol, in patients with reactive airways disease 1.
In terms of specific medication options, Betaxolol is preferred in patients with bronchospastic airway disease requiring a beta blocker, with a usual dose range of 5-20 mg daily 1. Bisoprolol and Metoprolol succinate are also options, but Betaxolol is often preferred due to its high cardioselectivity and lower risk of triggering bronchospasm 1.
From the FDA Drug Label
PATIENTS WITH BRONCHOSPASTIC DISEASE SHOULD, IN GENERAL, NOT RECEIVE BETA-BLOCKERS Because of its relative beta1-selectivity, however, bisoprolol fumarate may be used with caution in patients with bronchospastic disease who do not respond to, or who cannot tolerate other antihypertensive treatment.
Exacerbation of Bronchospastic Disease Patients with bronchospastic disease, should, in general, not receive beta-blockers, including metoprolol. Because of its relative beta 1 selectivity, however, metoprolol may be used in patients with bronchospastic disease who do not respond to, or cannot tolerate, other antihypertensive treatment
Suitable beta blockers for patients with a history of bronchospasm are:
- Bisoprolol: may be used with caution, with the lowest possible dose, and a beta2 agonist (bronchodilator) should be made available 2
- Metoprolol: may be used in patients with bronchospastic disease who do not respond to, or cannot tolerate, other antihypertensive treatment, with the lowest possible dose, and bronchodilators, including beta 2 agonists, should be readily available or administered concomitantly 3
From the Research
Suitable Beta Blockers for Patients with History of Bronchospasm
- Cardioselective beta-blockers are recommended for patients with a history of bronchospasm, as they are believed to be easier to reverse if bronchospasm occurs 4.
- Agents such as metoprolol, atenolol, and esmolol are considered suitable options for these patients 4.
- Noncardioselective beta-blockers should be avoided in patients with asthma, even in small doses, due to the risk of worsening bronchospasm 4, 5.
- Low-dose cardioselective beta-blockers, such as metoprolol, may be used in patients with chronic obstructive pulmonary disease (COPD) without altering the bronchodilator response to beta2-agonists 6.
Key Considerations
- When prescribing beta-blockers to patients with a history of bronchospasm, it is essential to start with a low dosage and monitor the patient closely for any signs of bronchospasm 4, 7.
- Bronchodilators should be readily available or coadministered with beta-blockers in case of bronchospasm 4.
- The choice of beta-blocker and dosage should be individualized based on the patient's specific condition and medical history 7, 8.