jwilzewske: Beta-Blocker Meds and Spasms in Classical Musicians

During the past six months, I’ve received a dozen communications from classical musician friends and CMT readers with questions and suggestions about beta blocker medications and muscle spasms. I respond to the two common ones together here, for your interest.

Q: I tried Corgard® 80 mg for stage fright and almost right away began having wheezing and asthma. This has happened three times. Is it just my imagination or is it because of the Corgard®?
A: There are a variety of beta blockers available. Propranolol (Inderal®) and nadolol (Corgard®) and other non-selective β blockers often have more side-effects than metoprolol (Lopressor®) and atenolol (Tenormin®), which are selective for β1-adrenergic receptors. Corgard® is indicated for the management of patients with angina pectoris (chest pain due to coronary artery disease), in doses from 40 mg to 240 mg per day. Corgard® is also used in the management of hypertension, in doses from 40 mg up to 320 mg per day. It is used either alone or in combination with other blood pressure medicines, especially thiazide-type diuretics. Peak blood concentrations of nadolol usually occur within four hours after oral administration, although the propensity for asthma-like bronchospasm is not limited to the period around the peak concentration. The drug has a half-life from 20 to 24 hours, except in people with significantly decreased kidney function, in whom the half-life is considerably longer. Propranolol and nadolol both tend to have more bronchospasm asthma-type side-effects than selective beta blockers at equivalent β1-receptor blocking doses. You may want to visit your physician and discuss trying a low dose of one of the β1-selective beta blockers for your performance anxiety, instead of the Corgard®.

Q: My dose of Corgard® was recently increased, to bring my blood pressure down. Over the past month I notice a kind of spasticity when I am playing [piano]. It’s like there’s a sort of ‘ratcheting’ that the muscles in my arms and shoulders do. It takes more effort to begin a motion and then, once my arm is moving, it tends to jerk or ‘overshoot’ in an odd way. It’s about the same on the left and the right side. It’s worse when I first begin to play and also when I’ve been playing for a long time and I am getting fatigued. Is this something caused by the Corgard?
A: Propranolol (Inderal®) and nadolol (Corgard®) and other non-selective β blockers often have more skeletal muscle side-effects than metoprolol (Lopressor®) and atenolol (Tenormin®), which are selective for β1-adrenergic receptors. Since muscle spasms or other muscular side-effects don’t interfere with ordinary activities of daily living, there is not much in the medical literature about them. People tend not to mention them to their doctors very often and, because the effects are not severe or limiting ordinary ‘coarse-motor’ muscular activity, academic physicians and researchers tend not to write scholarly journal articles about these side-effects. Pharmaceutical companies have not sponsored research in these areas. But that doesn’t mean that the effects don’t exist. And the effects can be limiting or ‘severe’ for professional musicians, whose performance critically depends on fine motor control. I’ve mostly heard from pianists and string players concerning them. I have not heard from any woodwind or brass player who has complained of muscle spasms on a non-selective beta blocker like Corgard®, possibly because the scale or dimensions on which performance depends for those instruments is smaller than for piano, strings, or other instruments. There is actually some old literature that suggests that a non-selective beta blocker taken by itself may help reduce or suppress a type of muscle hyper-reactivity/spasticity called ‘clonus’, but that effect is dose-dependent. Other older journal articles on the neurophysiology and pharmacology of non-selective beta-blockers show that twitch or spasm is augmented or enabled by blocking beta2 receptors. Recent work has looked in detail at beta2 and beta3 receptors in skeletal muscle, with genomic and proteomic methods that weren’t available thirty to forty years ago when the early studies were done. And recent biomechanics modeling has quantitatively evaluated the respective contributions of (and differential strains between) different parts of muscle bellies in contraction, revealing how imbalances in contraction can originate [in a manner that plausibly could be affected by medications, as well as other factors]. So, yes, a ratchet-like, hyper-reflexive, twitchy muscle action is plausibly related to the non-selective beta blocker. Incidentally, if a beta blocker is combined with a thiazide or other potassium-wasting diuretic for blood pressure control, then an abnormal potassium level may contribute to the muscle spasms you are experiencing. You may want to visit your physician and discuss adjusting your medication regimen, or trying an appropriate dose of one of the beta1-selective beta blockers instead of the non-selective Corgard®.

Note: CMT should not be considered as medical advice, and the remarks in these blog posts are not a substitute for professional medical advice, diagnosis, or treatment. Never delay or disregard seeking professional medical advice from your physician, pharmacist, or other qualified healthcare provider because of something you have read on CMT. You should always speak with your doctor before you start, stop, or change any prescribed part of your care plan or treatment.

jwilzewske

Wednesday, May 14, 2008

Beta-Blocker Meds and Spasms in Classical Musicians

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