Review Suggests New Strategies of Managing Comorbid COPD, Hypertension

In a review published today in The New England Journal of Medicine, researchers discuss optimal approaches to treating hypertension in patients with chronic obstructive pulmonary disease (COPD), with a given patient’s underlying lung function and any coexisting conditions highlighted as important factors of drug therapy choice.

Hypertension affects approximately 1.13 billion people worldwide and is the most common concurrent disease among patients with COPD. Similar to hypertension, COPD and impaired lung function are associated with an increased risk of cardiovascular events, stressing the health risk attributed to patients with both conditions.

As the researchers note, “Adequate management of hypertension in patients with COPD requires an understanding of appropriate drug-therapy choices in view of other common, coexisting diseases in such patients.”

To examine the efficacy of current therapies available for patients with COPD and hypertension, the researchers conducted a review on the impact of antihypertensive drug classes on COPD exacerbations, hospitalizations, and adverse pulmonary outcomes, as well as cardioselective beta-blockers in patients who have COPD and hypertension with concomitant heart failure or coronary artery disease.

Antihypertensive and Beta-Blocker Treatment in Patients With COPD

The researchers indicate that although contemporary and traditional hypertension guidelines have not identified COPD as an attributable indication for certain antihypertensive therapies, clinicians should be aware of the factors influencing control of both strongly linked conditions.

“Knowledge of the pulmonary side effects of different classes of antihypertensive therapies, as well as interactions between antihypertensive drugs and agents used for pulmonary control, is essential for successful management,” said the study authors.

In analyzing the contemporary data on specific outcomes of antihypertensive therapy in patients with COPD, they note that the risk and benefits of these medications are limited due to a lack of solid outcome evidence within this group. Furthermore, treatment recommendations for patients with COPD have traditionally been based on the theoretical risks of the drug therapy, contributing to the inability in effectively distinguishing risk.

Although this complicates attributable data, the researchers recommend that pharmacokinetic and pharmacodynamic factors be considered in choosing antihypertensive agents for patients with COPD, along with underlying lung function and any additional coexisting conditions.

Among the antihypertensive medications available, the study authors cited thiazide diuretics as first-line treatment in patients with COPD. When used with other antihypertensive medications, thiazide diuretics exhibited no increase in COPD exacerbations compared with combination antihypertensive therapy that did not include a thiazide diuretic. Additionally, in patients who did not have a history of heart failure, antihypertensive therapy combined with a thiazide diuretic was associated with a reduced risk of hospitalizations for heart failure.

Typically considered first-line antihypertensive agents for the general population, angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are met with more caution in the review. The study authors highlight that when these agents are prescribed for patients with COPD, the risks and benefits must be considered in light of certain pulmonary issues.

Findings in observational cohort studies have suggested that ARBs and ACE inhibitors may provide both cardiovascular and pulmonary protection in patients with COPD, with 1 uncontrolled study finding that the use of either of these agents after hospitalization for COPD exacerbation was associated with a significant reduction in 90-day mortality. While promising, adverse events linked with cough in ACE inhibitor therapy could prove to limit its use among patients with COPD.

Beta-blockers are not recommended for treatment of hypertension in the current hypertension guidelines; however, researchers note that for patients who have hypertension with heart failure or have had a recent myocardial infarction, cardioselective beta-blockers such as bisoprolol and metoprolol may reduce the risk of death. If a survival benefit from beta-blockers is established in further studies, the researchers note that the use of cardioselective agents in patients with COPD and additional compelling indications for beta-blockade should be strongly considered.

If clinicians were to use beta-blockers, the researchers suggest that they use small initial doses in all patients, with slow dose escalation to minimize the risks of hypotension and bradycardia. Study authors additionally recommend that clinicians remain vigilant in order to avoid inadvertent worsening of pulmonary symptoms when beta-blocker therapy is initiated or the dose is increased.

“Despite the paucity of data from randomized studies of hypertension management in patients with COPD, the limited contemporary evidence supports the use of ACE inhibitors, ARBs, and thiazides after consideration of the risks of adverse effects and interactions with medications used for pulmonary control,” said the study authors.

Reference

Finks SW, Rumbak MJ, Self TH. Treating Hypertension in Chronic Obstructive Pulmonary Disease [published online January 22, 2020]. N Engl J Med. doi: 10.1056/NEJMra1805377.