Is chronic obstructive pulmonary disease (COPD) exacerbation a contraindication to intravenous (IV) adenosine administration?

COPD Exacerbation is a Contraindication to Intravenous Adenosine

Yes, COPD exacerbation is a contraindication to intravenous adenosine administration due to the significant risk of bronchospasm and respiratory failure.

Rationale Based on FDA Labeling

The FDA drug label for adenosine explicitly states that it is contraindicated in patients with:

• "Known or suspected bronchoconstrictive or bronchospastic lung disease (e.g., asthma)" 1

Additionally, the label warns:

• "Adenosine injection administration can cause dyspnea, bronchoconstriction, and respiratory compromise. Adenosine injection should be used with caution in patients with obstructive lung disease not associated with bronchoconstriction (e.g., emphysema, bronchitis)." 1

Physiological Mechanism

Adenosine can trigger bronchoconstriction through several mechanisms:

• Direct stimulation of adenosine receptors in bronchial smooth muscle
• Mast cell degranulation leading to histamine release
• Activation of vagal reflexes

Evidence from Clinical Experience

Case reports have documented severe adverse respiratory outcomes with adenosine administration:

• A case report described a patient with COPD who developed respiratory failure requiring 9 days of ventilatory support after receiving adenosine for supraventricular tachycardia 2
• Even patients without known pulmonary disease have developed severe bronchospasm following adenosine administration 3

Risk Assessment in COPD Exacerbation

During a COPD exacerbation:

• Patients already have increased airway inflammation and bronchial hyperreactivity
• Respiratory reserve is compromised
• Patients are more vulnerable to additional bronchoconstrictive stimuli

Management Considerations

For patients with COPD requiring treatment for supraventricular arrhythmias:

1. Consider alternative antiarrhythmic agents during active exacerbations
2. If adenosine must be used in stable COPD (not during exacerbation):
   • Pretreat with inhaled beta-2 agonists
   • Use a gradual titration protocol
   • Have resuscitation equipment immediately available
   • Have aminophylline ready as an antidote

Research on Stable COPD Patients

Some studies suggest adenosine may be used with caution in stable COPD patients:

• A study of patients with mild-to-moderate stable COPD found adenosine was generally well-tolerated when administered with prophylactic beta-2 agonists 4
• Another study showed reasonable safety in stable COPD patients with careful monitoring 5

However, these studies specifically excluded patients with active exacerbations and emphasized the need for careful patient selection.

Conclusion

The risk of precipitating severe bronchospasm and respiratory failure in a patient with an active COPD exacerbation outweighs the potential benefits of adenosine. Alternative treatments for supraventricular arrhythmias should be considered during COPD exacerbations.