Are cardioselective beta blockers (beta-adrenergic blocking agents) contraindicated in patients with Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Cardioselective beta blockers are not contraindicated in patients with COPD, and their use is supported by recent evidence as a safe and potentially beneficial treatment option for patients with concurrent cardiovascular disease. The most recent and highest quality study, published in 2022 1, suggests that beta-blockers, including both beta 1-selective and non-selective agents, can be safely used in patients with COPD and cardiovascular disease, and may even reduce COPD exacerbations and mortality. When prescribing cardioselective beta blockers to COPD patients, it's advisable to start with a low dose and gradually titrate upward while monitoring for respiratory symptoms. Key points to consider include:

• The selectivity of cardioselective beta blockers, such as metoprolol, bisoprolol, and atenolol, which preferentially block beta-1 receptors in the heart while having minimal effect on beta-2 receptors in the lungs, especially at lower doses.
• The importance of monitoring for respiratory symptoms and adjusting the dose as needed.
• The potential benefits of treating cardiovascular conditions with cardioselective beta blockers, which may outweigh the small theoretical risk of bronchospasm in most COPD patients.
• The distinction between COPD and asthma, as patients with classical pulmonary asthma may worsen their condition with nonselective beta-blockers or agents with low beta 1-selectivity, as noted in the 2018 study 1.
• The recommendation from the 2008 European Society of Cardiology guidelines 1 that agents with documented effects on morbidity and mortality, such as ACEIs, β-blockers, and ARBs, are recommended in patients with co-existing pulmonary disease.

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.

Cardioselective beta blockers are not explicitly contraindicated in patients with COPD. However, the label notes that 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. The changes induced by beta-blockade were reversed by bronchodilator therapy 2.

From the Research

Cardioselective Beta Blockers in COPD Patients

• Cardioselective beta blockers are not contraindicated in patients with Chronic Obstructive Pulmonary Disease (COPD) 3, 4, 5, 6, 7
• Studies have shown that cardioselective beta blockers are generally well tolerated in COPD patients and do not significantly reduce lung function or increase the risk of exacerbations 4, 5, 6, 7
• The use of cardioselective beta blockers in COPD patients with a clear cardiovascular indication for these medications is associated with a lower risk of acute exacerbations and death 4
• However, the use of beta blockers in COPD patients without overt cardiovascular disease may not prevent COPD exacerbations and may paradoxically increase the risk of COPD-related hospitalization and mortality 4

Key Findings

• A meta-analysis of randomized, placebo-controlled, blinded trials found that cardioselective beta blockers did not significantly decrease the forced expiratory volume in 1 second (FEV1) or affect the responsiveness of the FEV1 to beta-agonist administration in COPD patients 7
• A systematic review of randomized, blinded, controlled trials found that cardioselective beta blockers produced no statistically significant change in FEV1 or respiratory symptoms compared to placebo in COPD patients 5, 6
• The available evidence suggests that cardioselective beta blockers can be considered for patients with COPD, but should be administered with careful monitoring 3, 5, 6