Q:

9/12/2012
Thoughts on starting allergy immunotherapy for a patient who is on a selective beta blocker medication (Coreg)?

A:

Thank you for your inquiry.

As far as beta-blockers in general, for your convenience, copied below is the summary statement regarding the use of beta-blockers during aeroallergen immunotherapy. This was copied from the most recent Immunotherapy Parameters (1). This Parameter is of course available to you free of charge online via the website of the Joint Council of Allergy, Asthma, and Immunology. The paragraph subsequent to this summary statement discussed the nuances underlying this recommendation.

"Beta-Blockers and ACE inhibitors Summary Statement 37: Exposure to beta-adrenergic blocking agents is a risk factor for more serious and treatment- resistant anaphylaxis. Concomitant use of beta-blockers and allergen immunotherapy should be carefully considered from an individualized risk/benefit standpoint and incorporate the patient’s preferences in the medical decision- making process."

Source: Allergen immunotherapy: A practice parameter third update: The Journal of Allergy and Clinical Immunology Vol. 127, Issue 1, Supplement, Pages S1-S55.

These guidelines do not make a distinction between cardioselective and non cardioselective blockers. It is important to remember that anaphylaxis differs from asthma. There is certainly a rationale for the use of a selective beta blocker versus a nonselective beta blocker in caring for a patient with asthma. However, anaphylaxis is not only characterized by the potential for airway obstruction, but also the potential for shock. When one views the cause of mortality attributable to airway obstruction versus shock and cardiovascular complications, it is clear that deaths can occur from involvement of either system, and in some series, the deaths are almost equally attributable to each. Thus, beta blockers are considered a relative contraindication regardless of whether or not they are selective or nonselective.

Theoretically, the risk may be less since there is less respiratory beta blockade, but there is no study quantifying how much less the risk would be. If you are interested in a more complete discussion of the use of beta blockers in immunotherapy, please see the reference noted below.

Thank you again for your inquiry and we hope this response is helpful to you.

Reference:
1.Phil Lieberman, Stephen F. Kemp, John Oppenheimer, David M. Lang, I. Leonard Bernstein, Richard A. Nicklas; The Journal of Allergy and Clinical Immunology, October 2005 (Vol. 116, Issue 4, Pages 933-936.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology