Wheeze and reduced peak flow in a 55-year-old man with asthma after starting propranolol
A pharmacovigilance case for causality assessment: work out which drug is responsible, grade the reaction's severity and seriousness, and defend a causality category using the WHO-UMC causality assessment.
WHO-UMC causality assessment
- Framework
- WHO-UMC causality assessment
- You decide
- Suspect drug, reaction, severity, seriousness, causality
The case
Presentation
A 55-year-old man, known to have asthma, presents to the emergency department with a two-day history of worsening wheeze and shortness of breath. He has been finding it increasingly difficult to speak in full sentences.
Medication history
- Beclometasone/formoterol 200/6 micrograms, one puff as required, for the past three years. Used on average twice a day.
- Propranolol 10 mg twice daily, started two days ago for anxiety.
- Lisinopril 10 mg once daily for hypertension, taken for the last five years.
- Paracetamol 500 mg occasionally for headaches. No other changes to his regular medication. He has not started any new over-the-counter or herbal remedies.
Timeline
- Day 0: Propranolol started.
- Day 1: He noticed a mild increase in chest tightness, which he attributed to anxiety.
- Day 2: His symptoms progressed, with persistent wheeze and breathlessness. He used his reliever inhaler several times without relief, so he presented to the emergency department.
Examination and investigations
On arrival, he is alert, sitting upright, speaking in short sentences. Respiratory rate 24/min, oxygen saturation 92% on room air, heart rate 110 bpm, blood pressure 140/85 mmHg. He is afebrile. Chest examination reveals widespread expiratory wheeze. Peak expiratory flow (PEF) is 150 L/min, which is 40% of his predicted value. Arterial blood gas shows PaO2 8.8 kPa, PaCO2 4.5 kPa, pH 7.41. Chest X-ray is normal. Blood tests show a white cell count of 8.2 × 10^9/L with no eosinophilia, C-reactive protein 6 mg/L.
What happened on stopping
Propranolol was discontinued on arrival. He was treated with salbutamol nebulisations and a course of oral prednisolone 40 mg daily for five days. His symptoms improved over the next 12 hours. His PEF rose to 350 L/min, close to his best, the following morning. He was admitted to the medical short-stay unit for 24 hours for observation, and then discharged home with a tapering course of prednisolone, and his usual asthma inhalers.
Rechallenge
Rechallenge with propranolol was not performed.
Alternative causes
A viral respiratory infection was considered as a possible alternative cause. However, he had no fever, coryzal symptoms, or purulent sputum. His C-reactive protein was within the normal range. There were no environmental or occupational triggers identified. His asthma had been well controlled on his reliever inhaler, and he had not had an exacerbation in the previous year.
What you are asked to do
- Identify which of the patient's drugs is the suspect, and say why the others are not.
- Name the reaction and grade its severity.
- Decide whether it is serious by regulatory criteria, which is not the same as severe.
- Assign a causality category under the WHO-UMC causality assessment and justify it from the timeline, the dechallenge and the alternative causes.
- State the management and what should be reported.
The suspect drug and the graded answer are deliberately not on this page: working them out is the exercise.
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A free account opens the trainer: name the suspect drug, grade the reaction and commit to a causality category, then see how your assessment compares and why.
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Educational content for students and clinicians in training. It does not replace professional judgement, local protocols or current prescribing information.