From the Guidelines
Beta blockers can worsen bronchospasm in patients with asthma, but this contraindication is relative, not absolute, and they may be used under close medical supervision with careful consideration of the risks and benefits. The use of beta blockers in asthma is a concern due to their potential to trigger bronchospasm by blocking beta-2 receptors in the airways, which are responsible for bronchodilation 1. Non-selective beta blockers pose a higher risk compared to cardioselective beta blockers like bisoprolol, metoprolol succinate, or nebivolol, which are preferred due to their greater selectivity for beta-1 receptors 1.
The historical contraindication of beta blockers in asthma is based on older studies with high initial dosages in young patients with severe asthma 1. However, more recent guidelines suggest that asthma is not an absolute contraindication to the use of beta blockers, especially in older patients where severe asthma is less common 1. The 2015 GINA global strategy report recommends that beta blockers can be used in patients with asthma under close medical supervision, weighing the risks against the benefits 1.
Key considerations for the use of beta blockers in patients with asthma include:
- Starting with low doses of cardioselective beta blockers
- Close monitoring for signs of airway obstruction, such as wheezing or shortness of breath
- Alternative medications should be considered first for conditions like hypertension, angina, or arrhythmias
- The long-term safety of cardioactive inhaled pulmonary drugs is uncertain and should be reassessed in patients with heart failure 1.
Given the potential risks, the use of beta blockers in patients with asthma should be approached with caution, and alternative treatments should be prioritized whenever possible. If beta blockers are necessary, a cardioselective agent at the lowest effective dose, combined with close monitoring, is the recommended approach 1.
From the FDA Drug Label
PATIENTS WITH BRONCHOSPASTIC DISEASE SHOULD, IN GENERAL, NOT RECEIVE BETA-BLOCKERS. Because of its relative beta1 selectivity, however, atenolol may be used with caution in patients with bronchospastic disease who do not respond to, or cannot tolerate, other antihypertensive treatment
Exacerbation of Bronchospastic Disease Patients with bronchospastic disease, should, in general, not receive beta-blockers, including metoprolol.
Beta blockers can worsen bronchospasm in patients with asthma. Beta blockers, such as atenolol and metoprolol, are generally not recommended for patients with bronchospastic disease, including asthma, as they can exacerbate the condition. However, in some cases, beta blockers with relative beta1 selectivity, like atenolol and metoprolol, may be used with caution in patients with bronchospastic disease who do not respond to or cannot tolerate other antihypertensive treatments. It is essential to use the lowest possible dose and have a beta2-stimulating agent (bronchodilator) available 2, 3.
From the Research
Beta Blockers and Bronchospasm in Asthma
- Beta blockers can worsen bronchospasm in patients with asthma, particularly non-cardioselective beta blockers 4, 5.
- Cardioselective beta blockers, such as metoprolol and atenolol, are considered safer alternatives and may be used in patients with asthma, but should be started at a low dosage and under direct medical observation 4.
- The risk of asthma worsening from systemic and local use of non-selective β-blockers outweighs any potential benefits for their clinical indications 5.
- Topical and systemic prescription of cardio-selective β-blockers is not associated with a significant increased risk of moderate or severe asthma exacerbations 5.
Key Considerations
- Clinicians should avoid noncardioselective beta-blockers in asthmatics, even in small doses, such as those administered as eye drops 4.
- The significance of beta2-blockade usually varies with the patient's ventilatory condition, with more serious consequences being anticipated in patients with more severe asthma 4.
- More prospective real-life studies are needed to evaluate the risk of long-term use of β-blockers in patients with asthma 5.
- Some studies suggest that beta blockers may have beneficial effects on airway inflammation and airway hyperresponsiveness in some patients with asthma, but further studies are needed to confirm this 6, 7.