In this case study, we outline a likely case of propranolol-induced asthma. Mr. J.S. is a 62-year-old male with a past medical history significant for essential tremor, mild persistent asthma, hypertension, and hyperlipidemia. His asthma has been well controlled for several years with fluticasone/salmeterol 100/50 mcg one inhalation twice daily and albuterol MDI as needed, which he reports using less than once weekly.
He presents to his primary care provider complaining of worsening hand tremors that are interfering with writing and eating. Propranolol immediate release is initiated at 10 mg twice daily for essential tremor. Over the next several weeks, Mr. J.S. reports partial improvement in tremor, but continued functional impairment. The propranolol dose is titrated to 20 mg three times daily.
Approximately two weeks after the dose increase, Mr. J.S. began experiencing increased shortness of breath, wheezing, and nighttime cough. He attributes these symptoms to seasonal allergies and increases his use of albuterol to several times per day. Despite this, his respiratory symptoms continue to worsen.
He presents to the emergency department with acute dyspnea and wheezing and is admitted for an asthma exacerbation. During hospitalization, he requires frequent nebulized albuterol/ipratropium treatments, systemic corticosteroids, and supplemental oxygen. His home medications are continued, including propranolol.
At discharge, Mr. J.S. is prescribed a higher-dose inhaled corticosteroid/long-acting beta-agonist (fluticasone/salmeterol 250/50 mcg twice daily) and a prednisone taper. No changes are made to the propranolol, which remains at 20 mg three times daily.
At follow-up two weeks later, Mr. J.S. reports improved breathing but an ongoing need for daily rescue inhaler use. His tremor is well controlled, and propranolol is continued without reassessment of its role in the recent asthma exacerbation.
Propranolol-Induced Asthma: Key Points
- Nonselective beta-blockers like propranolol can precipitate bronchospasm in patients with asthma (excellent board exam nugget).
- Dose escalation increases beta-2 blockade and risk of respiratory adverse effects.
- Failure to recognize medication-induced disease worsening can lead to a prescribing cascade.
- Alternative tremor therapies (e.g., primidone or a beta-1 selective agent with caution) should be considered in patients with reactive airway disease.
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