Is metoprolol contraindicated in patients with chronic obstructive pulmonary disease (COPD)?

Is Metoprolol Contraindicated in COPD Patients?

No, metoprolol is not contraindicated in patients with COPD and should not be withheld when there are compelling cardiovascular indications such as heart failure, post-myocardial infarction, or coronary artery disease. 1, 2

Key Distinction: COPD vs. Asthma

• Asthma remains an absolute contraindication to all beta-blockers, whereas COPD is only a relative contraindication that can be safely managed with cardioselective agents like metoprolol. 1, 3
• The FDA label for metoprolol states that "patients with bronchospastic disease should, in general, not receive beta-blockers," but explicitly notes that "because of its relative beta-1 selectivity, however, metoprolol may be used in patients with bronchospastic disease who do not respond to, or cannot tolerate, other antihypertensive treatment." 4

Evidence for Safety and Efficacy

• The European Society of Cardiology recommends that cardioselective beta-blockers with documented effects on morbidity and mortality, such as metoprolol, are used in patients with cardiac conditions even when they have co-existing COPD. 1
• Cardioselective beta-blockers reduce mortality in COPD patients with cardiovascular disease, and the survival benefit outweighs potential respiratory risks. 1, 2
• Meta-analyses demonstrate that cardioselective beta-blockers do not produce clinically significant declines in lung function and are not associated with increased respiratory adverse events. 3
• A Cochrane systematic review of 20 studies found that cardioselective beta-blockers produced no change in FEV1 or respiratory symptoms compared to placebo, even in patients with severe COPD or reversible obstruction. 5

Practical Prescribing Algorithm

Initiation:

• Start metoprolol outside of COPD exacerbations when the patient is clinically stable. 1, 6
• Begin with metoprolol tartrate 25-50 mg twice daily or metoprolol succinate (extended-release) 50 mg once daily. 1
• The FDA recommends using the lowest possible dose and considering smaller doses three times daily instead of larger doses twice daily to avoid higher peak plasma levels. 4

Titration:

• Gradually up-titrate every 2-4 weeks if no signs of worsening COPD or heart failure occur. 1
• Target dose is metoprolol tartrate up to 200 mg daily or metoprolol succinate up to 200 mg once daily. 1
• Target resting heart rate of 50-60 beats per minute unless limiting side effects occur. 1

Monitoring:

• Monitor for signs of worsening heart failure, bronchospasm, or respiratory symptoms during initiation and titration. 1
• Monitor blood pressure and heart rate at each visit. 1
• Ensure bronchodilators, including beta-2 agonists, are readily available or administered concomitantly. 4

Critical Management Principles

If respiratory deterioration occurs:

• Reduce the dose of metoprolol rather than discontinuing it completely. 1
• For patients experiencing a COPD exacerbation, temporary dose reduction may be necessary, but complete discontinuation should be avoided if possible. 1

Discontinuation precautions:

• Never abruptly discontinue metoprolol in patients with coronary artery disease. 4
• The FDA warns that severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported following abrupt discontinuation. 4
• If discontinuation is necessary, gradually reduce the dose over 1-2 weeks. 1, 4

Common Pitfalls to Avoid

• Do not assume all beta-blockers are equally safe in COPD—the distinction between cardioselective agents (metoprolol, bisoprolol, nebivolol) and non-selective agents (carvedilol, propranolol) is clinically crucial. 3, 2
• Non-selective beta-blockers are absolutely contraindicated in COPD due to beta-2 receptor blockade causing bronchospasm. 3, 2
• Do not withhold cardioselective beta-blockers from COPD patients with established cardiovascular indications based solely on the presence of COPD, as this represents inappropriate withholding of life-saving therapy. 1, 2
• Beta-blockers have traditionally been considered contraindicated in COPD, but current evidence demonstrates this concern is overemphasized for cardioselective agents. 7

Supporting Evidence from Clinical Studies

• A study of 50 CAD patients with COPD (including 21 with severe COPD) receiving metoprolol at mean doses of 92.5-189 mg daily showed no significant decrease in FEV1 and no adverse respiratory events. 8
• Research demonstrates that selective beta-1 blockers considerably increase survival in COPD patients with ischemic heart disease, particularly after myocardial infarction, and with chronic heart failure. 6
• Even intravenous metoprolol has been safely administered to patients with COPD without inducing clinical bronchospasm in most patients, though small declines in pulmonary function tests may occur. 9