Prescribing dilemmas
Salbutamol plus propranolol?
Dr Neil Wilson describes an anxious, hypochondriac patient on salbutamol who insists he
can also safely take propranolol, which he has already tried to no ill-effect
B
‘ eta-blockers can kill.’ This was
the stark message I felt ought
to be impressed on Phil. I did not
want to unduly alarm him but con-
sidered he should be fully aware of
the possible risks of him taking pro-
pranolol.
A well-known patient
Phil has been my patient for more
than 10 years and, as he attends
rather more often than usual for
a 36-year-old male, is well known
to me. He is a bluff but honest
and likeable salesman in a local
IT shop. His past medical history
features the typical inclusions of
appendicectomy, tonsillectomy
and minor fractures but little seri-
ous of note. His frequent consul-
tations arise from his chronic
anxiety state: he can – and does –
worry about, well, potentially any-
thing and everything, from global
issues such as climate change to
local controversies over water
supply and schools, but his par-
ticular anxieties relate to his own
health.
So his occasional ble-
pharospasm mushrooms in his
imagination into a motor neurone
disease and the odd ectopic beat is
magnified up to a life-threatening
arrhythmia. Similarly an acute viral
diarrhoea would seem to Phil to
herald an ulcerative colitis (requir-
ing ileostomy) and that tension
headache marks an inoperable
brain tumour.
In short, Phil is a hypochon-
driac and maybe this is not a sur-
prise given his parents, as they, too,
have consulted me for many years
and, alas, are both chronically
hypochondriac too. Neither of
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them have forgiven me for wean-
ing them off diazepam, but fortu-
nately Phil has read widely about
his affliction and readily agrees
sedatives are not indicated for it,
but instead he has clocked up
many hours over the years of clin-
ical psychologist input.
This has indeed taken the edge
off his more extreme manifesta-
tions of worry about his health, eg
he no longer phones up to ask for
CCU admission to monitor his sud-
den tachycardia. Phil has also
gained considerable insight into
his symptoms and is now much
more likely to acknowledge that his
tremor and tachycardia arise from
anxiety rather than thyrotoxicosis childhood of any wheeze or ‘bron-
or ischaemic heart disease, but he chitis’ and no note of bron-
remains relatively often troubled by chodilator therapies either.
such symptoms.
Wheezy with dust
A friend’s propranolol In his late teens, however, he
Then he took a propranolol recalled being ‘a bit tight in the
tablet. This had been given to chest’ when he swept out a ver y
him by a friend whose enthusiasm dusty garage doing odd jobs in a
for snooker was matched only by long summer holiday. It was then
his great praise for the calming of that he had been prescribed a
the performance tremor of his salbutamol inhaler. There was no
hands resulting from 40mg pro- note in the records of his peak flow
pranolol. Phil joked that that his then, but Phil was adamant he had
prowess at snooker had not been not been wheezy since, provided he
advanced, but he felt distinctly avoided very dusty conditions.
and wonderfully calmer for a few He had, however, tried using
hours and had noted no ill-effects this inhaler after a particularly
during this time. He had there- stressful job interview when he felt
fore hot footed it to me to supply he could not inspire easily. No
him with some more of this effi- relief had resulted though, and this
cacious remedy! episode seemed much more likely
A dilemma rapidly emerged: a to have been due to the ‘air
salbutamol inhaler loomed large in hunger’ of anxiety than asthma.
his repeat medication list – so Phil I explained to Phil why I avoided
must be asthmatic surely? We dug prescribing beta-blockers to
deeper into his voluminous notes. patients with asthma, highlighting
There was no mention at all in his the occasional severe, even fatal,
Prescriber 19 April 2008 43
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Prescribing dilemmas

bronchospasm that has sometimes sensible enough to comply, I went

resulted. Phil countered this with ahead with a regular repeat pre-
his obser vation that he only scription for propranolol 40mg
wheezed on the rare occasions he twice a day.
was exposed to a lot of dust and Since all this happened in 2003
pointed out he had been Phil has had no episodes of bron-
‘absolutely fine’ after taking his chospasm and he continues to feel
friend’s propranolol. The marked a lot less anxious. Indeed he now
anxiolytic effect he had experi- quite often only takes one propra-
enced from propranolol under- nolol 40mg a day. His efficiency at
standably lead him to be very keen work has improved a lot, to the
indeed that I prescribe them for extent that he regularly benefits
him regularly. from performance-related bonuses
and so he is, in his own words,
Spirometry results ‘dead chuffed’!
I suggested we should check and
evaluate his respiratory function by Science vs art of medicine
spirometr y, ideally both before I could have rigidly stuck to the
and after dosing with propranolol, ‘science of medicine’ and refused
to confirm his impression that no to give Phil any propranolol. This
significant bronchospasm would would have been the safest option
result. and a wholly defensible strategy.
The summary of product char- However the ‘art of medicine’ –
acteristics for propranolol states involving our attempts to try and
that its peak plasma concentration do the best for our patients –
occurs one to two hours after dos- surely prompts us to occasionally
ing in fasting subjects. Phil was challenge received wisdoms and
therefore prevailed upon to attend even take risks, provided always
our practice nurse one morning that these are minimised, if there
before he had eaten to have are great benefits to be gained by
spirometry performed just before so doing
taking 40mg propranolol, and then
occupy himself for two hours while Dr Wilson is a GP in the Forest of
sat in our waiting room before fin- Bowland, Lancashire
ishing with another spirometr y
reading. As he predicted both sets
of respirator y function readings
were identical.
Phil accepted that the manu-
facturer’s advice was ‘not to be
used if there is a history of bron-
chospasm’, but in view of these
spirometry results he assumed he
could take a beta-blocker safely,
provided he avoided ver y dusty
atmospheres, but if he should
somehow be so inadvertently
exposed he would stop taking any
propranolol and use a salbutamol
inhaler instead.
As he was now fully informed
and understood the potential risks
and as I was confident that Phil was

46 Prescriber 19 April 2008 www.escriber.com