Which antihypertensive drug class is absolutely contraindicated in patients with asthma?

Beta-Blockers Are Absolutely Contraindicated in Asthmatic Patients

The answer is d. beta-blockers—these are the only antihypertensive class with an absolute contraindication in asthma patients. 1, 2

Definitive Contraindication

• Asthma is listed as an absolute contraindication for beta-blockers according to European Society of Cardiology guidelines for heart failure management. 1
• This absolute contraindication applies specifically to asthma bronchiale, distinguishing it from COPD which is noted as NOT being a contraindication. 1
• Even cardioselective beta-1 blockers like metoprolol carry an absolute contraindication when active asthma is present, according to American College of Cardiology guidelines. 2

Why Beta-Blockers Are Uniquely Dangerous in Asthma

• Severe bronchoconstriction can occur even in patients with mild asthma, and the severity of response is unpredictable. 3
• Low doses can trigger severe reactions—even topical timolol eye drops for glaucoma have induced severe bronchospasm in asthmatics. 3
• Non-selective beta-blockers completely block the bronchodilating effect of rescue beta-2 agonists, leaving patients without effective treatment during an attack. 4
• Cardioselective beta-1 blockers lose their selectivity at higher doses (approximately 200 mg daily for metoprolol), effectively becoming non-selective and blocking bronchial beta-2 receptors. 2

Safety Profile of Other Antihypertensive Classes

ACE Inhibitors (Option a)

• Not absolutely contraindicated, but use with caution. 4
• Can induce cough and potentially increase bronchial hyperresponsiveness by preventing bradykinin metabolism. 4, 5
• May trigger asthma attacks in susceptible patients, but this is not an absolute contraindication. 5

Diuretics (Option b)

• No contraindication in asthma. 3
• Considered a safe alternative for hypertension treatment in asthmatics. 3

Angiotensin II Receptor Antagonists/ARBs (Option c)

• No contraindication in asthma. 1
• Preferred alternative when ACE inhibitors cause cough. 1

Calcium Channel Blockers (Option e)

• No contraindication—actually preferred in asthmatic patients. 3, 4
• Have modest bronchodilating effects and can provide some protection against bronchoconstriction. 4
• Recommended as the preferred antihypertensive choice for patients with airway disease. 4
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are specifically recommended as alternatives to beta-blockers in asthmatic patients with cardiovascular conditions. 2

Clinical Pitfalls to Avoid

• Never assume cardioselectivity provides adequate safety—even beta-1 selective agents are absolutely contraindicated in active asthma. 2
• Do not prescribe beta-blockers for any indication in asthmatics (including hypertension, glaucoma, or anxiety) when safe alternatives exist. 3
• Patients with suspected asthma or bronchial disease should be referred for specialist care before any consideration of beta-blocker therapy. 1