What is the best beta blocker for patients with asthma?

From the Guidelines

Beta blockers such as bisoprolol, metoprolol succinate, or nebivolol are the best options for patients with asthma who require beta blocker therapy, as they are more selective β1-adrenoceptor antagonists. These medications are preferred due to their cardioselectivity, which reduces the risk of bronchospasm in asthmatic patients 1. When prescribing these medications to asthmatic patients, it's essential to start with the lowest possible dose and gradually titrate upward while monitoring for respiratory symptoms, such as wheezing or shortness of breath. Some key points to consider when using beta blockers in asthmatic patients include:

• Starting with low doses of cardioselective beta blockers, such as bisoprolol (1.25-2.5 mg daily) or metoprolol succinate (25-50 mg daily), to minimize the risk of bronchospasm 1.
• Close monitoring for signs of airway obstruction, such as wheezing or shortness of breath, is crucial when using beta blockers in asthmatic patients 1.
• Non-selective beta blockers, such as propranolol, carvedilol, and labetalol, should be avoided in asthmatic patients due to their potential to trigger bronchospasm by blocking both beta-1 and beta-2 receptors 1.
• The use of beta blockers in asthmatic patients should be done under close medical supervision by a specialist, with consideration of the risks for and against their use 1.

From the FDA Drug Label

In asthmatic patients, metoprolol reduces FEV 1 and FVC significantly less than a nonselective beta-blocker, propranolol, at equivalent beta 1-receptor blocking doses Beta 1-selectivity of bisoprolol fumarate has been demonstrated in both animal and human studies No effects at therapeutic doses on beta 2-adrenoceptor density have been observed. 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 best beta blocker for patients with asthma is likely to be a beta 1-selective blocker, such as metoprolol or bisoprolol, as these have been shown to have less effect on beta 2-adrenoceptors in the lungs, which are responsible for bronchodilation.

• Metoprolol has been shown to reduce FEV1 and FVC significantly less than a nonselective beta-blocker, propranolol, at equivalent beta 1-receptor blocking doses 2.
• Bisoprolol has also been demonstrated to be beta 1-selective, with no effects on beta 2-adrenoceptor density at therapeutic doses, and has been shown to have minimal effects on pulmonary function in asthmatic patients 3. However, it is essential to note that beta blockers should be used with caution in patients with asthma, and the decision to use them should be made on a case-by-case basis, taking into account the individual patient's condition and medical history.

From the Research

Beta Blockers in Asthma

• The use of beta blockers in patients with asthma is a complex issue, with different types of beta blockers having varying effects on asthma outcomes 4, 5.
• Non-selective beta blockers are generally considered to be contraindicated in patients with asthma, as they can cause severe bronchoconstriction and worsen asthma symptoms 4, 6.
• Cardio-selective beta blockers, on the other hand, may be safer for use in patients with asthma, with some studies suggesting that they do not increase the risk of asthma exacerbations 5, 7.
• The study by 5 found that cardio-selective beta blockers were not associated with an increased risk of moderate or severe asthma exacerbations, and that the reluctance to use these medications in patients with asthma may not be justified.
• Another study by 7 found that the cardio-selective beta blocker bisoprolol did not impair the bronchodilator response to salbutamol in patients with asthma, suggesting that it may be a safe option for use in these patients.

Recommended Beta Blockers

• Based on the available evidence, cardio-selective beta blockers such as bisoprolol may be a suitable option for patients with asthma who require beta blocker therapy 5, 7.
• However, it is essential to weigh the potential benefits and risks of beta blocker use in patients with asthma, and to carefully monitor their asthma symptoms and lung function while on these medications 4, 5.
• The study by 4 suggests that cardio-selective beta blockers should be used in low doses and only when strongly indicated, and that other therapeutic options should be considered first.

Key Findings

• Non-selective beta blockers can worsen asthma symptoms and are generally contraindicated in patients with asthma 4, 6.
• Cardio-selective beta blockers may be safer for use in patients with asthma, but should be used with caution and in low doses 5, 7.
• The use of beta blockers in patients with asthma requires careful consideration of the potential benefits and risks, and close monitoring of asthma symptoms and lung function 4, 5.