Should Bisoprolol Be Stopped During Acute COPD Exacerbation?
No, bisoprolol should NOT be stopped during an acute COPD exacerbation in patients with hypertension or other cardiovascular indications. Continue the beta-blocker through the exacerbation while treating the COPD appropriately with corticosteroids and bronchodilators.
Rationale for Continuing Beta-Blockers During COPD Exacerbations
Guideline-Based Recommendations
The European Society of Cardiology explicitly states that the majority of patients with heart failure and COPD can safely tolerate β-blocker therapy, and that mild deterioration in pulmonary function and symptoms should not lead to prompt discontinuation 1
Agents with documented effects on morbidity and mortality such as beta-blockers are recommended in patients with co-existing pulmonary disease 1
The 2022 Hypertension guidelines emphasize that beta-blockers (including both beta-1-selective and non-selective agents) in patients with COPD and cardiovascular disease are not only safe but also reduce all-cause and in-hospital mortality 1
Beta-1-selective beta-blockers may even reduce COPD exacerbations according to meta-analysis data 1
Safety Profile of Bisoprolol in COPD
Bisoprolol is a cardioselective (beta-1-selective) agent that has minimal effect on beta-2 receptors in the bronchial system at therapeutic doses 2
The FDA label confirms that bisoprolol at doses of 5-20 mg showed only slight, asymptomatic increases in airway resistance at doses of 20 mg and higher, and these changes were reversed by bronchodilator therapy 2
Cardioselective beta-blockers do not affect the action of bronchodilators but reduce the heart rate acceleration caused by their use 1
Management During Acute Exacerbation
Continue Beta-Blocker While Treating COPD
Treat the COPD exacerbation with standard therapy: systemic corticosteroids (prednisone 30-40 mg daily for 5 days), short-acting bronchodilators, and antibiotics if indicated 3
Monitor for any worsening respiratory symptoms, but do not automatically discontinue bisoprolol 1
Ensure nebulizers are driven by compressed air rather than oxygen if the patient has hypercapnia 4
When to Exercise Caution
A history of asthma (not COPD) should be considered a contraindication to the use of any β-blocker 1
If new or significantly worsening bronchospasm occurs that does not respond to bronchodilator therapy, consider temporary dose reduction rather than complete cessation 1
Start beta-blockers at low doses and titrate gradually in COPD patients, but once established, maintain therapy through exacerbations 1, 5
Evidence from Recent Trials
The BICS Trial (2024)
The largest randomized trial of bisoprolol in COPD patients (n=515) found that bisoprolol was well tolerated with similar rates of serious adverse events compared to placebo (14.5% vs 14.3%) 6
Bisoprolol was not associated with an excess of respiratory adverse reactions 7
While bisoprolol did not reduce exacerbations in patients without cardiovascular disease, it did not increase exacerbations or cause harm 6
Clinical Context
Beta-blockers should not be used in COPD patients who lack cardiovascular indications, as they provide no benefit for COPD itself 8
However, in patients with established cardiovascular disease (hypertension, heart failure, post-MI), the cardiovascular benefits far outweigh any minimal respiratory effects 1, 8
Common Pitfalls to Avoid
Do not reflexively discontinue beta-blockers during COPD exacerbations - this is a common error that deprives patients of critical cardiovascular protection 1
Do not confuse COPD with asthma - asthma is a true contraindication to beta-blockers, while COPD is not 1
Do not use non-selective beta-blockers (like propranolol) in COPD patients - only cardioselective agents like bisoprolol should be used 1, 5
Avoid starting beta-blockers during an acute exacerbation, but if already established, continue them 5