What is the approach to using beta (beta blockers) in patients with end-stage Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Beta blockers can be used cautiously in patients with end-stage COPD, particularly when there are compelling indications such as heart failure, coronary artery disease, or arrhythmias, as they have been shown to reduce all-cause and in-hospital mortality in these patients. The preferred approach is to start with a cardioselective beta blocker (such as metoprolol, bisoprolol, or atenolol) at a low dose and gradually titrate upward while monitoring for respiratory symptoms, as supported by the most recent evidence from 2022 1. For example, metoprolol might be initiated at 12.5-25 mg twice daily and slowly increased as tolerated. During initiation and dose adjustments, patients should be closely monitored for worsening respiratory symptoms, including increased wheezing, shortness of breath, or decreased exercise tolerance. If respiratory deterioration occurs, reducing the dose or discontinuing the medication may be necessary. For patients with severe COPD exacerbations, temporarily holding beta blockers might be appropriate until respiratory status stabilizes. This cautious approach is justified by evidence showing that cardioselective beta blockers generally do not significantly worsen lung function in COPD patients, and the cardiovascular benefits often outweigh the potential respiratory risks, as noted in studies from 2008 2 and 2018 3.

Some key points to consider when using beta blockers in patients with end-stage COPD include:

• The importance of starting with a low dose and gradually titrating upward to minimize the risk of respiratory adverse effects
• The need for close monitoring of respiratory symptoms during initiation and dose adjustments
• The potential benefits of beta blockers in reducing mortality and morbidity in patients with COPD and cardiovascular disease
• The consideration of alternative treatments, such as ivabradine, diltiazem, or verapamil, in patients with COPD and asthma or chronic obstructive pulmonary disease with positive bronchoreactivity.

Overall, the use of beta blockers in patients with end-stage COPD requires a careful and individualized approach, taking into account the patient's specific clinical circumstances and the potential benefits and risks of treatment, as supported by the most recent and highest quality evidence 1.

From the FDA Drug Label

Pulmonary function studies have been conducted in healthy volunteers, asthmatics, and patients with chronic obstructive pulmonary disease (COPD). Doses of bisoprolol fumarate ranged from 5 to 60 mg, atenolol from 50 to 200 mg, metoprolol from 100 to 200 mg, and propranolol from 40 to 80 mg In some studies, slight, asymptomatic increases in airways resistance (AWR) and decreases in forced expiratory volume (FEV 1) were observed with doses of bisoprolol fumarate 20 mg and higher, similar to the small increases in AWR also noted with the other cardioselective beta-blockers. The changes induced by beta-blockade with all agents were reversed by bronchodilator therapy.

The approach to using beta blockers in patients with end-stage Chronic Obstructive Pulmonary Disease (COPD) is to use them with caution, as they may cause slight increases in airways resistance and decreases in forced expiratory volume. However, beta 1-selective beta blockers like bisoprolol fumarate may be a better option due to their minimal effect on beta 2-adrenoceptors. Key points to consider:

• Dose: Start with a low dose and monitor the patient's response.
• Monitoring: Closely monitor the patient's pulmonary function and adjust the dose or discontinue the medication if necessary.
• Bronchodilator therapy: Have bronchodilator therapy available to reverse any changes induced by beta-blockade. 4

From the Research

Approach to Using Beta Blockers in End-Stage COPD

The approach to using beta blockers in patients with end-stage Chronic Obstructive Pulmonary Disease (COPD) is complex and requires careful consideration of the potential benefits and risks.

• The use of beta blockers, especially cardioselective ones, has been associated with a lower risk of acute exacerbations and death in patients with COPD, particularly those with a clear cardiovascular indication for these medications 5, 6.
• However, the use of beta blockers in COPD patients without overt cardiovascular disease may not prevent COPD exacerbations and may even increase the risk of COPD-related hospitalization and mortality 5, 7.
• Cardioselective beta blockers, such as bisoprolol, metoprolol, or nebivolol, are considered safe for patients with cardiovascular diseases and COPD, and can be used in managing this patient cohort 6, 8.
• Nonselective beta blockers may induce bronchospasm and are not recommended for COPD patients 6.
• The beta blocker treatment should be started outside exacerbation of COPD and from a small dose, with careful monitoring for possible new symptoms, such as emergence/increase of shortness of breath, cough, or changes in dosing of other drugs 6, 8.

Key Considerations

• The decision to use beta blockers in patients with end-stage COPD should be individualized, taking into account the patient's cardiovascular risk factors, COPD severity, and other comorbidities 5, 9.
• The available evidence suggests that cardioselective beta blockers do not produce a significant short-term reduction in airway function or in the incidence of COPD exacerbations, but long-term data are limited 8, 7.
• Beta blockers should be prescribed with caution in patients with COPD, including those with a cardiac indication for beta blockers, due to the potential for conflicting results and biases in the existing evidence 7.