Can beta blockers be administered to patients with Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Beta blockers can be administered to patients with Chronic Obstructive Pulmonary Disease (COPD), particularly cardioselective beta blockers, as they have been shown to be safe and effective in reducing all-cause and in-hospital mortality, as well as COPD exacerbations, as demonstrated in a recent meta-analysis 1.

Key Considerations

• Cardioselective beta blockers, such as metoprolol, bisoprolol, and atenolol, are preferred due to their reduced risk of bronchospasm compared to non-selective beta blockers.
• Patients with COPD and cardiovascular disease, such as coronary heart disease or peripheral arterial disease, may benefit from beta blocker therapy, as it can reduce their risk of morbidity and mortality.
• When initiating beta blocker therapy in COPD patients, it is recommended to start with a low dose and gradually titrate up while monitoring for respiratory symptoms, as suggested by the European Society of Cardiology guidelines 2.

Important Factors to Consider

• A history of asthma should be considered a contraindication to the use of any beta blocker, and inhaled beta-agonists should be administered as required in patients with COPD.
• Close follow-up is essential, especially during the first few weeks of treatment, to monitor for any adverse effects or worsening of respiratory symptoms.
• For patients with severe or unstable COPD, consultation with both pulmonology and cardiology may be beneficial to optimize management and minimize potential risks.

Summary of Recommendations

• Use cardioselective beta blockers, such as metoprolol or bisoprolol, in COPD patients with compelling indications, such as heart failure or coronary artery disease.
• Start with a low dose and gradually titrate up while monitoring for respiratory symptoms.
• Consider consultation with both pulmonology and cardiology for patients with severe or unstable COPD.

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.

Beta blockers can be administered to patients with COPD, but it is essential to monitor for potential increases in airways resistance and decreases in forced expiratory volume, especially at higher doses. The effects of beta-blockade can be reversed with bronchodilator therapy 3.

From the Research

Administration of Beta Blockers to COPD Patients

• Beta blockers can be administered to patients with Chronic Obstructive Pulmonary Disease (COPD), but with caution and careful consideration of the potential risks and benefits 4, 5, 6.
• Selective β1-blockers, such as bisoprolol, metoprolol, or nebivolol, are considered safe for patients with cardiovascular diseases and COPD, as they have been shown to increase survival rates in patients with COPD and ischemic heart disease or chronic heart failure 4, 6.
• Nonselective β1-blockers may induce bronchospasm and are not recommended for COPD patients, while beta-blockers with intrinsic sympathomimetic activity may have a lower probability of bronchial obstruction, but have not been compared with cardioselective beta-blockers 4, 7.
• The use of beta blockers in COPD patients 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 4, 5.

Safety and Efficacy of Beta Blockers in COPD Patients

• The majority of observational studies have found statistically significant reductions in mortality with beta blocker use in COPD patients, although some higher quality studies have reported increased mortality 8.
• The risk of COPD exacerbations was reduced in about half of the studies, but there were significant biases that confounded the results 8.
• Beta blockers may inhibit the bronchodilator response to beta2-agonists in patients with COPD, and may also be associated with lower oxygen saturation during exercise 7.
• The clinical significance of these adverse effects is uncertain in view of the benefits of beta blocker treatment for cardiovascular disease 7.

Clinical Considerations

• Pneumologists and cardiologists should develop a detailed and standardized protocol to guide the use of selective beta(1)-blockers in everyday practice, which could significantly reduce the physicians' mistrust of beta-blockers in COPD patients 5.
• Large clinical trials are needed to dispel the mistrust of beta-blocker use in COPD patients and to provide more definitive evidence on their safety and efficacy 6, 8.