Bisoprolol Dosing Recommendations
The recommended starting dose for bisoprolol is 5 mg once daily for hypertension, and 1.25 mg once daily for heart failure. 1, 2, 3
Dosing by Indication
Hypertension
- Starting dose: 5 mg once daily 1
- In some patients, 2.5 mg may be an appropriate starting dose, particularly those with bronchospastic disease 1
- If the antihypertensive effect is inadequate, the dose may be increased to 10 mg and then, if necessary, to 20 mg once daily 1
- Beta blockers are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 2
Heart Failure
- Starting dose: 1.25 mg once daily 2, 3
- Titration schedule: Double the dose every 2-4 weeks as tolerated 2
- Typical titration pathway: 1.25 mg → 2.5 mg → 3.75 mg → 5 mg → 7.5 mg → 10 mg once daily 2, 4
- Target dose: 10 mg once daily 2, 3
- In the CIBIS-II trial, treatment with bisoprolol at target doses of 10 mg/day was associated with significant mortality reduction 2
Special Populations
Renal Impairment
- For patients with renal dysfunction (creatinine clearance less than 40 mL/min), the initial daily dose should be 2.5 mg 1
- In severe or end-stage renal failure, the dose should not exceed 10 mg once daily 5
- Bisoprolol has balanced clearance (both renal and hepatic), which prevents significant accumulation even in complete renal failure 5
Hepatic Impairment
- In patients with hepatic impairment (hepatitis or cirrhosis), the initial daily dose should be 2.5 mg 1
- Caution should be used in dose titration for these patients 1
Elderly Patients
- It is not necessary to adjust the dose in the elderly, unless there is also significant renal or hepatic dysfunction 1
Clinical Pearls and Monitoring
- Bisoprolol is one of only three beta blockers (along with carvedilol and metoprolol succinate) that have demonstrated mortality reduction in heart failure 3
- Monitor for signs of worsening heart failure, hypotension, and bradycardia during titration 2, 3
- For heart rate <50 beats/min with worsening symptoms, consider halving the dose or stopping bisoprolol if severe deterioration occurs 3
- In a study of patients with stable systolic heart failure, 63% of patients were able to reach the maximum target dose of 10 mg daily, with a mean achieved dose of 8.5 mg 4
- Avoid abrupt cessation of bisoprolol, which can lead to rebound hypertension or worsening ischemia 2, 3
Contraindications
- Asthma (COPD is not an absolute contraindication) 2
- Second- or third-degree heart block, sick sinus syndrome (without a permanent pacemaker) 2
- Sinus bradycardia (<50 beats/min) 2
Bisoprolol is a cardioselective beta-blocker that offers once-daily dosing convenience with proven efficacy in both hypertension and heart failure management. The dosing should be carefully titrated based on the indication and patient characteristics to achieve optimal therapeutic outcomes while minimizing adverse effects.