The safety of cardioselective β(1)-blockers in asthma: literature review and search of global pharmacovigilance safety reports

INTRODUCTION: Beta-blockers are key in the management of cardiovascular diseases but blocking airway β(2)-receptors can cause severe and sometimes fatal bronchoconstriction in people with asthma. Although cardioselective β(1)-blockers may be safer than non-selective β-blockers, they remain relatively contraindicated and under-prescribed. We review the evidence of the risk associated with cardioselective β(1)-blocker use in asthma. METHODS: We searched “asthma” AND “beta-blocker” in PubMed and EmbaseOvid from start to May 2020. The World Health Organization (WHO) global database of individual case safety reports (VigiBase) was searched for reports of fatal asthma or bronchospasm and listed cardioselective β(1)-blocker use (accessed February 2020). Reports were examined for evidence of pre-existing asthma. RESULTS: PubMed and EmbaseOvid searches identified 304 and 327 publications, respectively. No published reports of severe or fatal asthma associated with cardioselective β(1)-blockers were found. Three large observational studies reported no increase in asthma exacerbations with cardioselective β(1)-blocker treatment. The VigiBase search identified five reports of fatalities in patients with pre-existing asthma and reporting asthma or bronchospasm during cardioselective β(1)-blocker use. Four of these deaths were unrelated to cardioselective β(1)-blocker use. The circumstances of the fifth death were unclear. CONCLUSIONS: There were no published reports of cardioselective β(1)-blockers causing asthma death. Observational data suggest that cardioselective β(1)-blocker use is not associated with increased asthma exacerbations. We found only one report of an asthma death potentially caused by cardioselective β(1)-blockers in a patient with asthma in a search of VigiBase. The reluctance to use cardioselective β(1)-blockers in people with asthma is not supported by this evidence.