Is bisoprolol (beta-blocker) contraindicated in a patient with chronic obstructive pulmonary disease (COPD)?

Is Bisoprolol Contraindicated in COPD?

Bisoprolol is NOT contraindicated in patients with COPD, particularly when there is a compelling cardiovascular indication such as heart failure, post-myocardial infarction, or coronary artery disease. However, asthma remains an absolute contraindication. 1, 2

Key Distinction: COPD vs. Asthma

• COPD is a relative contraindication, not an absolute one—the decision depends on the presence of cardiovascular disease and the balance of risks versus benefits. 1, 3
• Asthma is an absolute contraindication to beta-blocker therapy and should never receive these agents. 1, 4
• Older guidelines (1997 British Thoracic Society) stated beta-blockers "should be avoided" in COPD 1, but this has been superseded by more recent evidence showing safety and mortality benefit when cardiovascular indications exist. 1, 2

When Bisoprolol Should Be Used in COPD

Beta-1 selective agents like bisoprolol reduce all-cause and in-hospital mortality in COPD patients with cardiovascular disease. 1

Strong Cardiovascular Indications:

• Heart failure with reduced ejection fraction: Bisoprolol is one of three beta-blockers (along with metoprolol succinate and carvedilol) with proven mortality benefit in heart failure. 1, 2
• Post-myocardial infarction: Beta-blockers significantly reduce mortality and reinfarction rates. 1, 3
• Coronary artery disease: Survival benefit outweighs respiratory risks. 1, 2

Practical Prescribing Algorithm

Initiation Protocol:

• Start during stable periods only—never during acute COPD exacerbations. 2, 3
• Begin with low doses: Bisoprolol 1.25 mg daily, titrating gradually every 2-4 weeks as tolerated. 2, 5
• Target dose: Up to 5-10 mg daily, based on tolerance and heart rate response. 2, 5
• Target heart rate: 50-60 beats per minute at rest. 2, 6

Monitoring Requirements:

• At each visit: Monitor for new or worsening dyspnea, cough, wheezing, or increased use of rescue bronchodilators. 2, 3
• Check heart rate and blood pressure at every titration visit. 2, 6
• Perform spirometry when patient is stable and euvolemic for at least 3 months to establish baseline. 6

Important Pulmonary Effects

Bisoprolol causes a small, dose-dependent reduction in FEV1, but this is generally well-tolerated and does not translate to increased symptoms in most patients. 7, 8

Expected Changes:

• Slight increases in airway resistance may occur at doses ≥20 mg, similar to other cardioselective beta-blockers. 7
• These changes are reversible with bronchodilator therapy. 7
• Beta-1 selectivity is maintained at therapeutic doses (5-10 mg), minimizing beta-2 receptor blockade in bronchial smooth muscle. 7, 3

Critical Safety Data and Caveats

Recent High-Quality Evidence Shows Conflicting Results:

The 2024 BICS trial (highest quality RCT) found that bisoprolol 5 mg daily did NOT reduce COPD exacerbations in high-risk COPD patients without overt cardiovascular disease. 5 This trial enrolled 515 patients with moderate-to-severe COPD and ≥2 exacerbations in the prior year, finding:

• No reduction in exacerbation rate (rate ratio 0.97,95% CI 0.84-1.13, P=0.72). 5
• Similar serious adverse event rates between bisoprolol and placebo (14.5% vs 14.3%). 5

A 2023 systematic review identified that the highest quality studies showed potential harm, with increased COPD exacerbations and mortality in some analyses. 9 The review concluded that beta-blockers should be prescribed with caution even when cardiac indications exist. 9

However, a 2021 review and multiple observational studies show that cardioselective beta-blockers are generally well-tolerated and reduce mortality when clear cardiovascular indications exist. 3, 10

The Critical Distinction:

• WITH cardiovascular disease (HF, post-MI, CAD): Beta-blockers reduce mortality and are recommended despite small reductions in lung function. 1, 2, 3
• WITHOUT cardiovascular disease: Beta-blockers do not prevent COPD exacerbations and may increase hospitalization risk—they should NOT be used. 10, 5

Management During COPD Exacerbations

If a COPD exacerbation occurs, reduce the bisoprolol dose rather than discontinuing completely. 2, 6

• Never abruptly discontinue in patients with coronary artery disease—this can precipitate acute coronary events. 2
• Temporary dose reduction is safer than complete withdrawal. 4, 6
• Gradual taper over 1-2 weeks if discontinuation is absolutely necessary. 2

Comparison with Other Beta-Blockers

Bisoprolol is preferred over non-selective beta-blockers (propranolol, carvedilol) in COPD patients due to its beta-1 selectivity. 1, 4, 6

• Cardioselective agents (bisoprolol, metoprolol, nebivolol) have less effect on bronchial beta-2 receptors. 1, 3
• Non-selective beta-blockers may induce bronchospasm and are not recommended. 3
• Bisoprolol and metoprolol are equally preferred for COPD patients with cardiovascular indications. 2, 3

Bottom Line for Clinical Practice

Use bisoprolol in COPD patients when there is a compelling cardiovascular indication (heart failure, post-MI, CAD), as the mortality benefit outweighs respiratory risks. 1, 2, 3 Start low, go slow, monitor carefully, and never use beta-blockers in COPD patients without cardiovascular disease. 10, 5