Cardioselective beta-blockers in patients with asthma and concomitant heart failure or history of myocardial infarction: when do benefits outweigh risks?

Beta Adrenergic Blocker Use in Patients With Chronic Obstructive Pulmonary Disease and Concurrent Chronic Heart Failure With a Low Ejection Fraction

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and present clinicians with diagnostic and therapeutic challenges. Beta-blockers are a cornerstone of CHF treatment, in patients with a low ejection fraction, while beta-agonists are utilized for COPD. These 2 therapies exert opposing pharmacological effects. COPD patients are at an increased risk of mortality from cardiovascular events. In addition to CHF, beta-blockers are used in a number of cardiovascular conditions because of their cardioprotective properties as well as their mortality benefit. However, there is reluctance among physicians to use beta-blockers in patients with COPD because of fear of inducing bronchospasms, despite increasing evidence of their safety and mortality benefits. The majority of this evidence comes from observational studies showing that beta-blockers are safe and well tolerated, with minimal effect on respiratory function. Furthermore, beta-blockers have been shown to lower the mortality risk in patients with COPD alone, as well as in those with COPD and CHF. Large clinical trials are needed in order to dispel the mistrust of beta-blocker use in COPD patients. The current evidence supports the use of cardioselective beta-blockers in patients with COPD. As the population continues to live longer, comorbidities become ever more present, and cardioselective beta-blockers should not be withheld from patients with COPD and coexistent CHF, because the benefits outweigh the risks.

Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey

OBJECTIVE

In a 1999 survey, community pharmacists from the Alsace region of France had a reasonably good knowledge of asthma treatment and prevention, but their skill in the use of asthma inhalation devices left room for improvement. Since then, health authorities have encouraged the involvement of community pharmacists in patient care and education in order to improve asthma control. The aim of this study was to assess the change in the knowledge of asthma management and inhaler technique skills of community pharmacists in the same geographic area after a 10-year interval.

METHODS

In 2009, 86 randomly selected community pharmacists from the Alsace region answered a standardized questionnaire about their theoretical knowledge of and practical attitude toward asthma management and inhaled delivery systems, following which their skills in the use of four inhalation devices (pressurized metered-dose inhaler (pMDI) with/without a spacer, breath-actuated pMDI and dry powder inhaler (DPI)) were evaluated.

RESULTS

Very few pharmacists were required to manage an acute asthma exacerbation at the pharmacy, but all responded well by administering a short-acting inhaled β2-agonist. Theoretical knowledge of asthma management (criteria of severity of asthma exacerbation, guidelines and drugs triggering asthma exacerbations) was still average. Compared with 1999, they were twice as confident in demonstrating inhaler use, and their skills in using the pMDI, breath-actuated pMDI and DPI had improved significantly (p < 0.001).

CONCLUSIONS

Since 1999, pharmacists' skill in the use of inhalers has improved, but theoretical knowledge of asthma management is still average, pointing to the importance of continuing pharmaceutical education.

The pharmacists' potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma

BACKGROUND

Despite of pharmacists' specialized knowledge of medication and his/her regular contact with patients, the expertise of the pharmacist may not be used enough yet. Furthermore, the potential of pharmacy dispensing data is underestimated.

OBJECTIVE

To provide targets for tailored interventions in asthma patients and to illustrate the potential value of pharmacists in the identification of these targets using individual pharmacy dispensing data.

SETTING

We performed a cross sectional retrospective analysis assessing the quality of asthma patients' pharmacotherapeutic treatment.

METHOD

Drug dispensing data from 2008 to 2009 were retrieved from a Dutch pharmacy database. All asthma patients were screened for potential suboptimal pharmacotherapy in 2009. Results were projected to a single community pharmacy to provide an estimate of the number of patients eligible for potential interventions.

MAIN OUTCOME MEASURES

(1) frequent use of short-acting β-agonists without preventive medication, (2) concomitant use of β-blockers, (3) multiple short courses of oral corticosteroids without using inhaled corticosteroids and 4) use of long-acting β-agonist without inhaled corticosteroids.

RESULTS

A total of 8,504 patients were eligible for analysis of the quality of their asthma treatment. 20.9 % of all asthma patients used >100 DDD short-acting β-agonists per year, whereas between 21.2 % (≥ 400 DDD) and 31.4 % (100-199 DDD) of these patients did not receive preventive medication. Approximately 5.2 % of the asthma patients are using β-blockers concomitantly and 21.8 % of them received non-cardioselective β-blockers. 6.3 % of the asthma patients received two or more oral courses of corticosteroids in 2008 and 17.4 % of these patients did not receive inhaled corticosteroids in 2009. 2.9 % of the patients used a long-acting β-agonists without inhaled corticosteroids. 8.4 % of the asthma patients using both long-acting β-agonists and inhaled corticosteroids received these drugs in two separate inhalers. We estimated that about 400 asthma patients could be identified in an average pharmacy population (8,000 patients) and 33 (95 % CI 22-44) of these patients would be eligible for interventions.

CONCLUSION

This study shows the potential for pharmacists to use their own pharmacy records to identify suboptimal therapy of asthma patients, who may be targets for tailored interventions.

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

BACKGROUND

Benefits outweigh risks of cardioselective beta-blocker therapy in patients with nonsevere asthma and a history of heart failure or myocardial infarction (MI). This review summarizes the risks versus benefits of using cardioselective beta-blockers in the treatment of hypertension in patients with asthma.

METHODS

We searched the English literature from 1976 to 2011 via PubMed, EMBASE, and SCOPUS using the following search terms: "beta-blocker treatment of hypertension" AND "asthma"; "cardioselective beta-blockers" AND "asthma." When pertinent articles were found, we assessed relevant articles cited in those papers. All studies related to cardioselective beta-blocker use in patients with asthma and hypertension were included.

RESULTS

Seven studies with patient populations ranging from 10 to 17 patients evaluated cardioselective beta-blockers in patients with asthma and hypertension. Atenolol and/or immediate-release metoprolol were evaluated in these studies. The duration of beta-blocker therapy in four studies was 1-8 weeks; two studies were single dose and one investigation lasted 8 months. Metoprolol and atenolol were generally well tolerated except at higher doses such as metoprolol >100 mg daily.

CONCLUSION

In the absence of concomitant cardiovascular disease, routine use of beta-blockers for the treatment of hypertension in patients with asthma should be avoided.

Carvedilol therapy after cocaine-induced myocardial infarction in patients with asthma

INTRODUCTION

Cocaine-induced myocardial infarction (MI) is well documented. Current literature recommends avoiding beta-blockers in the acute care setting, but after discharge from the hospital, benefits of beta-blocker use may outweigh risks in patients with recent MI resulting from cocaine use. Cardioselective beta-blocker therapy has been demonstrated to be beneficial in post-MI patients with nonsevere asthma. This review article is to compare the risks and benefits of using carvedilol in patients with asthma who have had cocaine-induced MI.

METHODS

The authors searched the English literature from 1984 to July 2010 via PubMed, EMBASE and SCOPUS using the following search terms: "cocaine-induced myocardial infarction AND treatment," "cocaine AND carvedilol," "beta blockers AND asthma," and "carvedilol AND asthma." All studies and case reports related to carvedilol use associated with bronchospasm in patients with asthma and carvedilol use after cocaine-induced MI were included.

RESULTS

Carvedilol has theoretical advantages in patients who use cocaine, but there are no controlled studies confirming the superior efficacy of this agent. Reports of carvedilol use in patients with asthma are rare, but findings include increased asthma symptoms and hospitalization in some patients. Fatal asthma has also been reported because of this noncardioselective beta-blocker.

CONCLUSIONS

Based on a lack of evidence supporting the theoretical advantages but documented risks associated with its use in patients with asthma, carvedilol should be avoided in asthma patients who have a history of cocaine-induced MI. Cardioselective beta-blockers should be used in post-MI patients with nonsevere asthma.

Beta-1 selective adrenergic antagonist landiolol and esmolol can be safely used in patients with airway hyperreactivity

This study was undertaken to clarify the effects of esmolol and landiolol, beta-1 selective adrenergic antagonists, on hyperreactive airways in both ovalbumin-sensitized guinea pigs and asthmatic patients. In the animal study, asthma was induced by ovalbumin. After control acetylcholine responses for total pulmonary resistance (Raw) and dynamic lung compliance (Cdyn) were obtained, the animals received propranolol, esmolol, or landiolol, and the same protocol was again performed. Sixty inpatients with coronary risk factors and asthma were enrolled in the human study. Under propofol anesthesia, the patients received saline, esmolol, or landiolol. To assess intubation-induced bronchoconstriction, the presence of wheezing was determined. The dose-response curves of Raw and Cdyn to acetylcholine were significantly elevated and declined in the ovalbumin-sensitized model compared with those in the control group. Neither esmolol nor landiolol had any effect on the acetylcholine-induced response curve in these sensitized animals. However, propranolol significantly enhanced Raw and reduced Cdyn in this model. Tracheal intubation increased the incidence of wheezing in asthmatic patients. However, there was no significant difference in the incidence of wheezing among these groups. The ultra-short-acting beta-1 selective adrenergic antagonists esmolol and landiolol can be safely used perioperatively in patients with airway hyperreactivity.

Rates of hospitalizations and emergency department visits in patients with asthma and chronic obstructive pulmonary disease taking beta-blockers

STUDY OBJECTIVE

To determine the rates of hospitalizations and emergency department (ED) visits during cardioselective and nonselective beta-blocker therapy in patients with asthma and/or chronic obstructive pulmonary disease (COPD).

DESIGN

Retrospective, observational cohort study.

DATA SOURCE

Electronic medical records database.

PATIENTS

A total of 11,592 adult patients with asthma and/or COPD, identified from August 1, 1997-December 31, 2005, who were taking beta-blockers for at least 30 days or had never received a beta-blocker (controls).

MEASUREMENTS AND MAIN RESULTS

Of these patients, 3062 were taking cardioselective and 690 nonselective beta-blockers; 7840 were controls. The primary end point for the beta-blocker groups was the rate of hospitalizations and ED visits/patient-year of beta-blocker therapy relative to the control group. In patients with asthma with or without concomitant COPD, cardioselective beta-blockers were associated with a relative risk of 0.89 (95% confidence interval [CI] 0.53-1.50) for hospitalizations and 1.40 (95% CI 1.20-1.62) for ED visits compared with controls. Nonselective beta-blockers were associated with a relative risk of 2.47 (95% CI 1.37-4.48) for hospitalizations and 1.21 (95% CI 0.91-1.62) for ED visits. In patients with COPD only, cardioselective beta-blockers were associated with a relative risk of 0.64 (95% CI 0.43-0.96) for hospitalizations and 1.19 (95% CI 1.02-1.39) for ED visits. Nonselective beta-blockers were associated with a relative risk of 1.02 (95% CI 0.52-2.02) for hospitalizations and 0.51 (95% CI 0.33-0.80) for ED visits.

CONCLUSION

In patients with asthma with or without COPD, both cardioselective and nonselective beta-blocker use increased hospitalizations and ED visits compared with controls. Thus, these patients should receive beta-blocker therapy only if their cardiac risk exceeds their pulmonary risk and if they have concomitant cardiac disease for which beta-blockers decrease mortality, such as previous acute myocardial infarction or chronic heart failure. In patients with COPD only, cardioselective beta-blockers slightly increased the risk of ED visits but reduced the risk of hospitalizations. Nonselective beta-blocker therapy in these patients reduced the rate of ED visits and total visits. These findings suggest a larger safety margin with beta-blocker therapy in patients with COPD only than in those with asthma with or without COPD.

Asthma and the unified airway

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

beta-Blocker therapy in veterans with asthma or chronic obstructive pulmonary disease

STUDY OBJECTIVES

To determine whether an association exists between health care resource use and beta-blocker therapy in patients with asthma or chronic obstructive pulmonary disease (COPD), and to determine whether any significant differences exist between type of beta-blocker agent administered and resource use.

DESIGN

Retrospective cohort study.

DATA SOURCE

Three Veterans Administration (VA) databases with information from hospitals and clinics in Iowa and Nebraska. Patients. A total of 8390 veterans with a diagnosis of asthma or COPD receiving treatment with a beta-blocker or another cardiovascular agent.

MEASUREMENTS AND MAIN RESULTS

Clinic visits and hospital admissions for asthma or COPD that occurred in 2000-2001 were identified using electronic administrative data files. Analyses were adjusted for comorbidity and patient demographics. Mean patient age was 67 years, and 97% of the patients were men. In unadjusted analyses, patients taking beta-blockers had more hospital admissions, similar inpatient length of stay (LOS), and fewer outpatient clinic visits for asthma or COPD. In adjusted analyses, however, no difference was noted in the odds of hospital admission or in LOS, and patients had fewer clinic visits related to asthma or COPD. The hazard ratio for hospital admission for asthma or COPD during the observation year was similar for patients taking and not taking beta-blockers, and no difference was noted with selective versus nonselective beta-blockers. However, the hospital admission rate was lower with atenolol than metoprolol.

CONCLUSION

Patients taking beta-blockers did not have more hospital admissions or clinic visits for their asthma or COPD than patients not taking these agents. When clinically indicated, beta-blockers-especially atenolol-should be considered for patients with asthma or COPD.

Multi-tasking RGS proteins in the heart: the next therapeutic target?

Regulator of G-protein-signaling (RGS) proteins play a key role in the regulation of G-protein-coupled receptor (GPCR) signaling. The characteristic hallmark of RGS proteins is a conserved approximately 120-aa RGS region that confers on these proteins the ability to serve as GTPase-activating proteins (GAPs) for G(alpha) proteins. Most RGS proteins can serve as GAPs for multiple isoforms of G(alpha) and therefore have the potential to influence many cellular signaling pathways. However, RGS proteins can be highly regulated and can demonstrate extreme specificity for a particular signaling pathway. RGS proteins can be regulated by altering their GAP activity or subcellular localization; such regulation is achieved by phosphorylation, palmitoylation, and interaction with protein and lipid-binding partners. Many RGS proteins have GAP-independent functions that influence GPCR and non-GPCR-mediated signaling, such as effector regulation or action as an effector. Hence, RGS proteins should be considered multifunctional signaling regulators. GPCR-mediated signaling is critical for normal function in the cardiovascular system and is currently the primary target for the pharmacological treatment of disease. Alterations in RGS protein levels, in particular RGS2 and RGS4, produce cardiovascular phenotypes. Thus, because of the importance of GPCR-signaling pathways and the profound influence of RGS proteins on these pathways, RGS proteins are regulators of cardiovascular physiology and potentially novel drug targets as well.