Can Nebivolol Cause Shortness of Breath?
Yes, nebivolol can cause shortness of breath (dyspnea), though this adverse effect occurs in only approximately 1% of patients according to FDA labeling data. 1
Mechanism and Incidence
Nebivolol is a highly selective β1-adrenergic receptor blocker, but like all beta-blockers, it retains some degree of β2-receptor antagonism that can theoretically affect bronchial smooth muscle. 1, 2 The FDA-approved prescribing information lists dyspnea as a reported adverse reaction occurring in 1% of patients treated with nebivolol 20-40 mg daily in controlled trials. 1
Post-marketing surveillance has identified bronchospasm as a recognized adverse reaction, though the exact frequency cannot be determined from spontaneous reporting. 1
Clinical Context: When Shortness of Breath is More Likely
Patients with pre-existing respiratory disease require special consideration:
Asthma patients: The FDA labeling explicitly warns that patients with asthma or other lung problems (such as bronchitis or emphysema) should inform their doctor before taking nebivolol. 1 However, the 2016 ESC guidelines clarify that beta-blockers are only relatively contraindicated in asthma, not absolutely contraindicated, and that cardioselective agents like nebivolol are preferred when beta-blockade is necessary. 3
COPD patients: Beta-blockers are NOT contraindicated in COPD, though cardioselective agents (bisoprolol, metoprolol succinate, or nebivolol) are preferred. 3 Clinical trial data in hypertensive patients with mild-to-moderate COPD showed nebivolol was safe during 2-week treatment periods, with only slight impact on FEV1. 4
Distinguishing Beta-Blocker Effects from Other Causes
When evaluating shortness of breath in a patient taking nebivolol, consider these alternative explanations:
Worsening heart failure: The FDA labeling specifically instructs patients to tell their doctor if they gain weight or have trouble breathing while taking nebivolol, as leg swelling (peripheral edema, occurring in 1% of patients) may indicate fluid retention. 1
Acute pulmonary edema: This has been reported in post-marketing surveillance as a serious adverse reaction. 1
Bradycardia-related symptoms: Excessive heart rate reduction (bradycardia occurs in up to 1% of patients) can cause dyspnea through reduced cardiac output. 1
Safety Profile in Respiratory Disease
Nebivolol demonstrates superior respiratory tolerability compared to older beta-blockers:
The drug's high β1-selectivity and nitric oxide-mediated vasodilatory effects result in minimal bronchoconstrictive effects. 2, 5, 6
Studies in patients with COPD showed nebivolol was well tolerated with similar day-to-day airway obstruction control compared to nifedipine. 4
The substantial dissociation between cardiac and pulmonary activity gives nebivolol a very good safety profile in hypertensive subjects with obstructive respiratory comorbidities. 5
Clinical Monitoring Recommendations
If shortness of breath develops in a patient taking nebivolol:
Assess for signs of heart failure (weight gain, peripheral edema, orthopnea). 1
Check heart rate for excessive bradycardia (may require dose adjustment or discontinuation). 1
In patients with known asthma, monitor for wheezing and lengthening of expiration, which would indicate airway obstruction requiring close medical supervision. 3
Consider spirometry if respiratory symptoms are new or worsening, particularly in patients without previously documented lung disease. 3
Important Caveat
Do not abruptly discontinue nebivolol if dyspnea develops. The FDA labeling explicitly warns against sudden cessation, as this can precipitate chest pain or myocardial infarction. 1 If discontinuation is necessary, the dose should be tapered gradually under physician supervision. 1