Which antihypertensive (blood pressure medication) should be avoided in patients with asthma?

From the Guidelines

Beta-blockers, particularly non-selective ones like propranolol and nadolol, should be avoided in patients with asthma due to their potential to cause bronchospasm and worsen asthma symptoms. According to 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 1, non-selective beta-blockers pose the highest risk as they block both beta-1 receptors (heart) and beta-2 receptors (lungs), preventing bronchodilation.

Key Points to Consider

• Even cardioselective beta-blockers such as metoprolol, atenolol, and bisoprolol can lose their selectivity at higher doses and should be used with caution in asthma patients 1.
• The mechanism involves blocking beta-2 receptors in bronchial smooth muscle, which prevents the natural bronchodilation process and can trigger bronchospasm in susceptible individuals.
• Alternative antihypertensive medications that are safer for asthma patients include:
  • Calcium channel blockers (amlodipine, diltiazem)
  • ACE inhibitors (lisinopril, enalapril)
  • Angiotensin II receptor blockers (losartan, valsartan)
  • Thiazide diuretics (hydrochlorothiazide)
• If a beta-blocker is absolutely necessary, a cardioselective agent at the lowest effective dose with careful monitoring is recommended, as stated in the guideline 1.
• It's also important to note that beta-blockers like nadolol should be avoided in patients with reactive airways disease, as mentioned in the guideline 1.

Clinical Implications

In clinical practice, when managing hypertension in patients with asthma, it's crucial to prioritize the use of antihypertensive medications that do not exacerbate asthma symptoms. By choosing alternative medications and using beta-blockers judiciously, clinicians can help minimize the risk of bronchospasm and improve patient outcomes.

From the FDA Drug Label

PATIENTS WITH BRONCHOSPASTIC DISEASE SHOULD, IN GENERAL, NOT RECEIVE BETA-BLOCKERS. Patients with bronchospastic disease, should, in general, not receive beta-blockers, including metoprolol.

Beta-blockers that should be avoided in patients with asthma (a type of bronchospastic disease) include:

• Atenolol
• Metoprolol However, it is noted that beta1 selectivity is not absolute, and the lowest possible dose should be used with caution, along with a bronchodilator 2, 3.

From the Research

Antihypertensive Medications to Avoid in Asthma Patients

• Non-selective beta-blockers should be avoided in patients with asthma, as they can worsen asthma symptoms and increase the risk of asthma exacerbations 4, 5, 6
• Specific non-selective beta-blockers that should be avoided include:
  • Oral timolol 5
  • Infusion of propranolol 5
  • Oral labetalol, oxprenolol, propranolol, and metoprolol in patients with a baseline asthma history 5
• Cardio-selective beta-blockers, such as bisoprolol, may be used in patients with asthma when strongly indicated and other therapeutic options are not available, but with caution and close monitoring 4, 7

Alternative Antihypertensive Medications

• Calcium channel blockers may be a suitable alternative for hypertensive patients with airway disease, as they have a minimal effect on airway function and do not exacerbate asthma symptoms 6
• Other antihypertensive medications, such as ACE inhibitors, should be used with caution in patients with asthma, as they may induce cough and bronchial hyperresponsiveness 6