Cardioselective beta-blocker treatment of hypertension in patients with asthma: when do benefits outweigh risks?

Do beta-adrenergic blocking agents increase asthma exacerbation? A network meta-analysis of randomized controlled trials

Beta-adrenergic blocking agents (abbreviated as beta-blockers) have been used for treating various cardiovascular diseases. However, the potential for asthma exacerbation is one of the major adverse effects of beta-blockers. This study aimed to compare the level of risk for an asthma attack in patients receiving various beta-blockers. We searched for randomized controlled trials (RCTs) of either placebo-controlled or active-controlled design. The current network meta-analysis (NMA) was conducted under a frequentist model. The primary outcome was the incidence of asthmatic attack. A total of 24 RCTs were included. Overall NMA revealed that only oral timolol [risk ratio (RR) = 3.35 (95% confidence interval (CI) 1.04–10.85)] and infusion of propranolol [RR = 10.19 (95% CI 1.29–80.41)] were associated with significantly higher incidences of asthma attack than the placebo, whereas oral celiprolol [RR = 0.39 (95% CI 0.04–4.11)], oral celiprolol and propranolol [RR = 0.46 (95% CI 0.02–11.65)], oral bisoprolol [RR = 0.46 (95% CI 0.02–11.65)], oral atenolol [RR = 0.51 (95% CI 0.20–1.28)], infusion of practolol [RR = 0.80 (95% CI 0.03–25.14)], and infusion of sotalol [RR = 0.91 (95% CI 0.08–10.65)] were associated with relatively lower incidences of asthma attack than the placebo. In participants with a baseline asthma history, in addition to oral timolol and infusion of propranolol, oral labetalol, oxprenolol, propranolol, and metoprolol exhibited significantly higher incidences of asthma attack than did the placebo. In conclusion, oral timolol and infusion of propranolol were associated with a significantly higher risk of developing an asthma attack in patients, especially in those with a baseline asthma history, and should be avoided in patients who present a risk of asthma.

Trial registration: PROSPERO CRD42020190540.

Use of Antihypertensive Medications and Uterotonics During Delivery Hospitalizations in Women With Asthma

OBJECTIVE

To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations.

METHODS

We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed.

RESULTS

Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01).

CONCLUSION

There may be an opportunity to reduce use of β-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.

Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension

We report a case of intravenous ephedrine administration that abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension and who was subsequently diagnosed postoperatively as having bronchial asthma. A 54-year-old man who had childhood asthma was scheduled for laparoscopic cholecystectomy at our institution. The preanesthetic interview suggested full resolution of his childhood asthma. His capnogram showed an airway obstructive pattern immediately after the initiation of mechanical ventilation. However, after administration of ephedrine due to low blood pressure during surgery, his obstructive capnogram reverted to normal. On postoperative day 3, he was diagnosed as having bronchial asthma. Furthermore, we found that small airway obstruction as indicated in his preoperative pulmonary function test (PFT) had been overlooked. Two important points arise from this case. First, the use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided. Second, clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.

Considerations of prescribers and pharmacists for the use of non-selective β-blockers in asthma and COPD patients: An explorative study

RATIONALE, AIMS, AND OBJECTIVES

Despite recommendations in prevailing guidelines to avoid the use of non-selective (NS) β-blockers in patients with asthma or COPD, on average, 10 patients per community pharmacy receive NS β-blockers monthly. The aim of our study was to identify the reasons of prescribers and pharmacists to treat asthma and COPD patients with NS β-blockers.

METHODS

Fifty-three community pharmacists in the Netherlands selected patients with actual concurrent use of inhalation medication and NS β-blockers. For at least 5 patients, each pharmacist screened all medication surveillance signals and actions taken at first dispensing. Each pharmacist selected 3 different initial prescribers for a short interview to explore their awareness of the co-morbidity and reasons to apply NS β-blockers.

RESULTS

Pharmacists identified 827 asthma/COPD patients with actual use of NS β-blockers. From these, 153 NS β-blocker prescribers were selected and interviewed (64 general practitioners, 45 ophthalmologists, 24 cardiologists, and 20 other prescribers). One hundred seven prescribers were aware of the drug-disease interaction of the asthma or COPD co-morbidity when initiating the NS β-blocker, and 46 were not. From these, 40 prescribers did not consider the contraindication to be relevant. For 299 patients, medication surveillance signals and actions at first dispensing were retrieved. Patients used predominantly ocular timolol (39.8%), and the oral preparations propranolol (30.8%) and carvedilol (15.1%). In 154 cases, the pharmacy system generated a warning alert.

CONCLUSIONS

A substantial number of prescribers was unaware of the co-morbidity or did not regard NS β-blockers contraindicated, despite prevailing clinical guidelines. Improvement programs should target prescribers' awareness and knowledge of NS β-blockers in patients with asthma or COPD.

Identifying asthma triggers

Asthma has many triggers including rhinosinusitis; allergy; irritants; medications (aspirin in aspirin-exacerbated respiratory disease); and obesity. Paradoxic vocal fold dysfunction mimics asthma and may be present along with asthma. This article reviews each of these triggers, outlining methods of recognizing the trigger and then its management. In many patients more than one trigger may be present. Full appreciation of the complexity of these relationships and targeted therapy to the trigger is needed to best care for the patient with asthma.

Driving forces behind the past and future emergence of personalized medicine

Personalized medicine can be seen as a continuously developing approach to tailoring treatments according to the individual characteristics of a patient. In some way, medicine has always been personalized. During the last decade, however, scientific and technological progress have made truly personalized healthcare increasingly become reality. Today’s personalized medicine involves targeted therapies and diagnostic tests. The development of targeted agents represents a major investment opportunity to pharmaceutical companies, which have been facing the need to diversify their business due to an increasingly challenging market place. By investing into the development of personalized therapies, pharmaceutical companies mitigate a major part of the risks posed by factors such as patent expiries or generic competition. Viewing upon personalized medicine from different perspectives points out the multi-causality of its emergence. Research efforts and business diversification have been two main driving forces; they do supplement each other, however, are not jointly exhaustive in explaining the emergence of this approach. Especially in the future, a number of further stakeholders will impact the evolution of personalized medicine.