Continuing Education Activity

Beta-2 adrenergic receptors are cell-surface receptors clinically taken advantage of in the management of bronchospasm as in patients with bronchial asthma and chronic obstructive pulmonary disease. Medications targeting these receptors are either agonistic or antagonistic. Agonistic drugs used in the stimulation of the receptors are either selective to the beta-2 subtype or nonselective, which stimulates all beta subtypes, including beta-2, while there are no selective beta-2 antagonists. This activity will highlight the mechanism of action of beta-2 receptors, the indications, administration routes, adverse effects, monitoring, contraindications, and some instructions related to the use of medications aiming at the receptors, mainly on patients with bronchospastic diseases.

Objectives:

• Identify the different types of medications that exert their effects on beta-2 adrenergic receptors.
• Describe the adverse effects associated with beta-2 adrenergic receptor agonists and antagonists.
• Review the toxicity of beta-2 adrenergic receptor agonists and antagonists.
• Outline the importance of improving care coordination amongst the interprofessional team to enhance the delivery of care for patients receiving targeting beta-2 receptors.

Indications

Beta-adrenergic receptors are transmembrane glycoprotein structures that elicit a response inside the cell when interacting with catecholamines. They belong to a major receptor family (R7G) containing other receptors responding to substances other than catecholamines, and these receptors are coupled with guanine nucleotide (GTP) binding proteins (G proteins). Beta receptors divide into three subtypes; beta-1 (B1), beta-2 (B2), and beta-3 (B3). Other adrenergic receptors are alpha-1 and alpha-2 receptors.

Beta 2 receptors are predominantly present in airway smooth muscles. They also exist on cardiac muscles, uterine muscles, alveolar type II cells, mast cells, mucous glands, epithelial cells, vascular endothelium, eosinophils, lymphocytes, and skeletal muscles.

Natural catecholamines are nonspecific in their effects on the body, as they can stimulate all types and subtypes of adrenergic receptors. However, different catecholamines and synthetic drugs have affinities towards different receptor subtypes. Therefore, some synthetic drugs are considered “selective” to a specific adrenergic receptor or a subtype while other compounds are not.

Natural hormones stimulate B2 receptors in the body as well as by synthetic compounds; epinephrine (adrenaline) is the most effective natural catecholamine agonist of B2, while norepinephrine (noradrenaline) is less effective on it, and epinephrine is the hormone responsible for B2 receptor stimulation in the physiological state. Synthetic agonists were sought to selectively stimulate specific receptors, unlike natural hormones, which have a low selectivity profile to minimize adverse effects. Beta receptors can be blocked by using synthetic drugs, but B2-selective blockers are yet to be found.

Beta-2 Receptor Agonists

These drugs are designed to mimic the natural effect of epinephrine and norepinephrine hormones on the body, thus called sympathomimetics, but to limit the stimulation to B2 receptors as much as possible to reduce adverse effects. They are mainly used to manage respiratory disorders such as chronic obstructive pulmonary disease (COPD) and asthma.[1]

B2 agonists further classify into short-acting, long-acting, and ultra-long-acting drugs.

Some FDA-approved short-acting B2 agonists (SABAs) are albuterol, levalbuterol, metaproterenol, and terbutaline, and they are prescribed for bronchospasm caused by COPD, bronchial asthma, or emphysema.

Some SABAs have off-label uses; albuterol is used in the treatment of hyperkalemia, and terbutaline is administered to postpone preterm labor and manage vascular extravasation.[2][3]

Long-acting B2 agonists (LABAs) are indicated as maintenance treatment of bronchoconstriction in patients with COPD, chronic bronchitis, and emphysema. FDA-approved LABAs include salmeterol, formoterol, and arformoterol.

Recently, clinical trials have started on ultra-long-acting B2 agonists (ULABAs) to find their effects as a long-term once-daily management method for COPD and asthma. Olodaterol is an example of an FDA-approved ULABA.

A dangerous off-label use for some B2 agonists is by bodybuilders and athletes for their anabolic and lipolytic properties.[4][5]

Beta-2 Receptor Antagonists (Blockers)

B2 antagonists are the compounds used to block the activation of B2 receptors. There are no FDA-approved selective B2 antagonists. Butoxamine is a non-FDA-approved B2-selective blocker used exclusively for research purposes as it has no clinical use.[6]

Mechanism of Action

B2 adrenergic receptors are coded on chromosome 5 and expressed predominantly in the smooth muscle cells of the airways. The receptor is composed of 8 alpha helices; three are extracellular, and five are intracellular. It is bound to and transmits its signals inside the cell through heterotrimeric G protein, specifically Gs protein. Gs protein consists of alpha, beta, and gamma subunits. B2 receptors are present in two forms; activated and inactivated, and there is an equilibrium between both forms in the body.

The activity of the B2 receptor is dependent on the alpha subunit of the Gs protein; it becomes activated when bound to GTP and inactivated when bound to GDP. Presumably, agonistic ligands of B2 receptors achieve their effects by stabilizing the Gs-GTP form so it would retain its intracellular activity, whereas B2 blockers arrest the receptor in Gs-GDP low-energy form hence preventing the reactivation of the receptor.[7][8]

The pathway of B2 receptor action begins when an agonist activates the receptor, causing the alpha subunit of the Gs protein to detach and reattach to adenylate cyclase, stimulating it to catalyze the conversion of adenosine triphosphate (ATP) into cyclic adenosine monophosphate (cAMP), which acts as a second messenger within the cell. In turn, cAMP initiates two routes leading to smooth muscle relaxation, the first is through freeing the catalytic subunit of protein kinase A enzyme, whose function is to phosphorylate various enzymes contributing to the relaxation of airway smooth muscles, and the second is by reducing calcium concentration inside the cell by preventing its extracellular influx, inhibiting its outflow from intracellular storage, and initiating sequestration of calcium ions in the cytoplasm, thus preventing muscle contraction. The same mechanism is responsible for uterine relaxation and is responsible for using B2 agonists in tocolysis.[3] B2 activation is also reported to increase the beating frequency of the cilia, decrease acetylcholine release, change vascular permeability, and modulate immune cell function.[7][1] B2 activation is also responsible for glycogenolysis.[9]

B2 adrenergic antagonists cause their effect by blocking the activation of B2 receptors, so all the processes mentioned above cease to continue. Theoretically, beta-blockers can cause exacerbation of symptoms in patients with asthma because they restrict the protective bronchodilatory effect of the natural epinephrine.[7]

Administration

B2 agonists are mostly given in inhaled forms-whether as a spray or nebulized to limit the systemic adverse effects and reduce the delivered dose to target only the respiratory system. They can also be given intravenously or intramuscularly in severe acute exacerbations of asthma, orally in cases of using LABAs or ULABAs in the long-term management of asthma or COPD, and subcutaneously.[10]

Adverse Effects

SABAs rarely have any adverse effects when used in the usual doses, but higher and systemic doses can have similar outcomes to sympathetic stimulation on the body; the most common is tremor. Other adverse effects include anxiety, palpitations, and tachycardia. Elevated SABA doses can also cause lactic acidosis, decreased serum potassium and magnesium levels, and hyperglycemia.[11][1]

LABAs can cause cardiac dysrhythmias and muscle cramps in normal doses in long-term use, especially when taken as the sole management drug for asthma without steroids. There is evidence of tolerance in the case of long-term use of LABAs.[1]

Systemic exposure to B2 agonists can cause systemic vasodilation, potentially leading to hypotension and can trigger headaches. Hypotension may also cause hypoxemia due to ventilation/perfusion mismatching in the lung.[12] The risk of myocardial infarction was found to be seven times higher in patients using beta-2 agonists compared to those who are not.[13]

Regular B2 agonist use in the treatment of asthma in the absence of corticosteroids may deteriorate in the chronic stage of the disease, as long-term tolerance to the antagonistic effect of B2 agonists is documented.[12]

B2 receptor-related side effects caused by beta-blockers include Raynaud phenomenon, hypoglycemia during exercise, muscle cramps, and increased airway resistance.[9]

Contraindications

Hypersensitivity is a contraindication for any substance, including B2 agonists and beta-blockers. B2 agonists require caution for patients with arrhythmias and cardiac problems. Hypokalemia is a contraindication for B2 agonists because it may lead to increased severity of the condition. Beta-blockers are not recommended for patients with bronchoconstrictive diseases such as asthma and COPD. They should be given with care to diabetic patients as it may increase the risk of hypoglycemic comas.[9]

Monitoring

The therapeutic index of beta-2 agonists is different for each chemical, and both therapeutic and adverse effects of similar doses can be different among individuals according to multiple factors, such as the severity of the condition and the length of the drug’s use, as well as other medications taken by the patient.

The plasma concentration of B2 agonists correlates with the severity of the toxicity. Direct monitoring of B2 agonists is not a regular procedure in clinical practice, as their efficacy and toxicity can be measured clinically or by using indirect tests. Nevertheless, there are some recognized tests for measuring drug concentration in the bloodstream, such as gas chromatography or liquid chromatography with mass spectrometry, high-performance liquid chromatography, fluorimetric detectors, and electrochemical detectors. Monitoring techniques are primarily used before athletic competitions to check for their use as anabolic agents.[5] Clinically, serum potassium and blood glucose require regular monitoring to manage any adverse effects early. The recurrence of asthma attacks is not an indicator of the efficacy of B2 agonists, as the main drug responsible for long-term effects is steroids.

Toxicity

B2 agonist toxicity can be accidental or intentional. The most dangerous complication caused by its toxicity is hypokalemia caused by the intracellular shift of potassium. The toxicity can also present as exaggerations of documented side effects, such as significant hypotension and presence of bounding pulse due to greater affection of the diastolic portion, supraventricular tachycardia or ventricular extrasystoles, tremors which can rarely but possibly reach the level of seizures, hyperglycemia, and lactic acidosis, tachypnea, and pupillary dilation. Very high doses can lead to psychosis and hallucinations.[4][14]

Beta-blockers such as propranolol and esmolol are considered antidotes for B2 agonist overdose as they antagonize the B2 receptor activation caused by them.[14][15]

There are some causes related to B2 receptors for beta-blocker contraindication; the most important one is in patients with asthma as it would cause increased bronchial resistance, thus increasing symptoms of asthma and other bronchospastic diseases.[9]

Enhancing Healthcare Team Outcomes

Asthma and COPD are common chronic diseases with multiple treatment guidelines throughout the world, but beta-2 agonists are an essential part of every guideline; this necessitates thorough and accurate knowledge of different aspects related to them, including the significant adverse effects and contraindications. Practitioners should always respect the individual difference between patients’ responses to treatment, so customization of treatment regimen according to all of the previous factors is a must.

Beta-2 agonists are not the first-line management drug for asthma, and patients require education about when and how to use them properly, as multiple studies showed that tolerance to B2 agonists is rapid if used incorrectly.

Patients with chronic respiratory inflammatory diseases should receive care from an interprofessional team of healthcare workers, including pulmonologists or allergists, family clinicians (MDs, DOs, PAs, NPs), pharmacists, and nurses, who should all understand the therapeutic use of beta-2 receptors and the drugs that exert inhibitory or agonistic effects on them. This knowledge will help both with therapy choices as well as monitoring for adverse events. This will require open communication and collaborative effort between all clinicians, specialists, nurses, and pharmacists, with each discipline empowered to offer suggestions and alert other team members to status changes. This will bring about better patient outcomes while minimizing potential adverse events from beta-2 receptor drugs. [Level 5] In this vein of thought, cardiologists and obstetricians should identify the clinical relevance of drugs affecting B2 receptors, which their patients may be taking, and adjust the medications they prescribe accordingly to improve efficacy and prevent adverse effects.

The general public needs more information about the dangerous outcomes of B2 agonists if used inappropriately or without medical advice, such as its use as an anabolic drug, and emergency physicians and nurses should have the training to identify the clinical picture of these drugs’ overdose correctly.