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[FRSM]

Effect of β blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study BMJ 2011; 342:d2549 doi: 10.1136/bmj.d2549 (Published 10 May 2011)


Abstract

Objective To examine the effect of β blockers in the management of chronic obstructive pulmonary disease (COPD), assessing their effect on mortality, hospital admissions, and exacerbations of COPD when added to established treatment for COPD.

Design Retrospective cohort study using a disease specific database of COPD patients (TARDIS) linked to the Scottish morbidity records of acute hospital admissions, the Tayside community pharmacy prescription records, and the General Register Office for Scotland death registry.

Setting Tayside, Scotland (2001–2010)

Population 5977 patients aged >50 years with a diagnosis of COPD.

Main outcome measures Hazard ratios for all cause mortality, emergency oral corticosteroid use, and respiratory related hospital admissions calculated through Cox proportional hazard regression after correction for influential covariates.

Results Mean follow-up was 4.35 years, mean age at diagnosis was 69.1 years, and 88% of β blockers used were cardioselective. There was a 22% overall reduction in all cause mortality with β blocker use. Furthermore, there were additive benefits of β blockers on all cause mortality at all treatment steps for COPD. Compared with controls (given only inhaled therapy with either short acting β agonists or short acting antimuscarinics), the adjusted hazard ratio for all cause mortality was 0.28 (95% CI 0.21 to 0.39) for treatment with inhaled corticosteroid, long acting β agonist, and long acting antimuscarinic plus β blocker versus 0.43 (0.38 to 0.48) without β blocker. There were similar trends showing additive benefits of β blockers in reducing oral corticosteroid use and hospital admissions due to respiratory disease. β blockers had no deleterious impact on lung function at all treatment steps when given in conjunction with either a long acting β agonist or antimuscarinic agent

Conclusions β blockers may reduce mortality and COPD exacerbations when added to established inhaled stepwise therapy for COPD, independently of overt cardiovascular disease and cardiac drugs, and without adverse effects on pulmonary function.

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[Nastydoc]

There were similar trends showing additive benefits of β blockers in reducing oral corticosteroid use and hospital admissions due to respiratory disease

на этой фразе я упала пацтул это как это так

[Nastydoc]

то есть по идее теперь надо добавлять ббл к терапии?

[besman_sk]

ХОЗЛ, в отличие от БА,собственно, и не был противопоказанием к назначению ББ.

"Which patients should get a b-blocker?....Contraindications
† Asthma [chronic obstructive pulmonary disease (COPD) is not
a contraindication].

ESC Guidelines 2407, European Heart Journal (2008) 29, 2388–2442
doi:10.1093/eurheartj/ehn309

Так что в ситуации ИБС (ХСН)+ХОЗЛ их нужно назначать.

[FRSM]

В марте мы затронули позицию: "Beta-blockers can precipitate bronchospasm and should therefore usually be avoided in patients with a history of asthma. When there is no suitable alternative, it may be necessary for a patient with well-controlled asthma, or chronic obstructive pulmonary disease (without significant reversible airways obstruction), to receive treatment with a beta-blocker for a co-existing condition (e.g. heart failure or following myocardial infarction). In this situation, a cardioselective beta-blocker should be selected and initiated at a low dose by a specialist; the patient should be closely monitored for adverse effects. Atenolol, bisoprolol, metoprolol, nebivolol, and (to a lesser extent) acebutolol, have less effect on the beta2 (bronchial) receptors and are, therefore, relatively cardioselective, but they are not cardiospecific. They have a lesser effect on airways resistance but are not free of this side-effect.

Contra-indications asthma (but see notes above), uncontrolled heart failure, Prinzmetal’s angina, marked bradycardia, hypotension, sick sinus syndrome, second- or third- degree AV block, cardiogenic shock, metabolic acidosis, severe peripheral arterial disease; phaeochromocytoma (apart from specific use with alpha-blockers, see also notes above)

Bronchospasm Beta-blockers, including those considered to be cardioselective, should usually be avoided in patients with a history of asthma or bronchospasm. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution and under specialist supervision.

Результаты Шотланского исследования были в процессе обработки, до него ничего аналогичного по дизайну и масштабам вроде не проводилось. Место трайла - в стране с одной из самых высоких в Европе заболеваемостью COPD.

[Yariko]

Сообщение от besman_sk

ХОЗЛ, в отличие от БА,собственно, и не был противопоказанием к назначению ББ.

"Which patients should get a b-blocker?....Contraindications
† Asthma [chronic obstructive pulmonary disease (COPD) is not
a contraindication].

ESC Guidelines 2407, European Heart Journal (2008) 29, 2388–2442
doi:10.1093/eurheartj/ehn309

Так что в ситуации ИБС (ХСН)+ХОЗЛ их нужно назначать.

при чем тут это, это всем известно. Ценность исследования в другом

Conclusions β blockers may reduce mortality and COPD exacerbations when added to established inhaled stepwise therapy for COPD, independently of overt cardiovascular disease and cardiac drugs, and without adverse effects on pulmonary function.

[besman_sk]

Сообщение от Khomitskaya

при чем тут это, это всем известно. Ценность исследования в другом

Спасибо, ценность исследования я понял после первого же прочтения. Суть поста в том , что ББ при ХОЗЛ и сопутствующих показаниях без сомнения нужны, а в свете новых данных "дважды" нужны.

Сообщение от Nastydoc

то есть по идее теперь надо добавлять ббл к терапии?

Однако же добавление ББ к стандартоной терапии ХОЗЛа без сопутствующих показаний, несмотря на воодушевляющие результаты данного исследования, думаю, об этом говорить несколько рано в отсутствии консенсусного мнения экспертов.

[Gilarov]

Я бы пока не был столь оптимистичен, ибо речь идет о ретроспективном исследовании и от назначения бета-блоков всем пациентам с ХОБЛ воздержался. Все же назначали их пациентам по поводу именно сердечной патологии. Далее,

independently of overt cardiovascular disease and cardiac drugs

верно лишь в отношении cardiac drugs, т. к.

Adjusted hazard ratios were calculated after correction for the following covariates: cardiovascular and respiratory hospital admissions, diabetes, smoking, age, sex, and cardiac drug use

, что, конечно же не может полностью говорить о тяжести сопутствующей кардиальной патологии.
Хотя, бета-блокеры, наверное могут устранять негативные последствия использования бета-агонистов и в этом причина их эффекта при ХОБЛ (88% бета-блокеров были кардиосерективными).

[Yariko]

Сообщение от Gilarov

Я бы пока не был столь оптимистичен, ибо речь идет о ретроспективном исследовании и от назначения бета-блоков всем пациентам с ХОБЛ воздержался.).

соглашусь

Сообщение от Gilarov

верно лишь в отношении cardiac drugs, т. к., что, конечно же не может полностью говорить о тяжести сопутствующей кардиальной патологии.

не соглашусь

Through matched propensity scoring analysis, our data suggest a 22% overall reduction in all cause mortality for patients with COPD when their inhaled treatment regimen includes β blockers. Importantly, our data also suggest there may be benefits when β blockers. Our Cox proportional hazard regression analyses
have shown that the additive benefits of β blockers were independent of other cardiovascular drugs and history of overt cardiovascular disease (ischaemic heart disease, heart failure, peripheral vascular disease). These findings suggest that β blockers have effects on reducing mortality in COPD in addition to the benefits gained by reducing cardiovascular risk.

We evaluated the effects of β blockers on all cause mortality independently of cardiovascular outcomes, including cardiac drug prescription and overt cardiovascular disease as measured by hospital admissions due to ischaemic heart disease, heart failure, or peripheral vascular disease (although a history of hypertension was unavailable for analysis from our database). Furthermore, when assessing the impact of β blocker use on all cause mortality, we performed a matched propensity scoring analysis, which is designed to minimise the effects of confounding by indication.

Сообщение от Gilarov

Хотя, бета-блокеры, наверное могут устранять негативные последствия использования бета-агонистов и в этом причина их эффекта при ХОБЛ (88% бета-блокеров были кардиосерективными).

да, вероятно

One possibility is that up-regulation of β2 adrenoceptors by chronic β blockade may improve the effectiveness of β2 agonists. Despite most of the β blockers in our study being relatively cardioselective, drugs such as atenolol and bisoprolol have been shown to exert significant β2 adrenoceptor antagonism even at therapeutic doses, which may result in β2
adrenoceptor up-regulation. Thus, up-regulation of β2 adrenoceptors by cardioselective β blockers seems plausible.