Bisoprolol Dosing in Heart Failure
For patients with heart failure, bisoprolol should be initiated at 1.25 mg once daily, with gradual titration every 1-2 weeks to a target dose of 10 mg once daily, as tolerated. 1
Initial Dosing and Titration Schedule
- Start with 1.25 mg once daily 1
- Titrate dose upward gradually if the preceding dose is well tolerated 1
- Follow this titration schedule: 1.25 mg → 2.5 mg → 3.75 mg → 5 mg → 7.5 mg → 10 mg 1
- Allow 1-2 weeks between dose increases to ensure stability 1
- Target dose is 10 mg once daily 1
- Total titration period typically takes weeks to months 1
Patient Selection and Prerequisites
- Patient should be on background therapy with ACE inhibitors (if not contraindicated) 1
- Patient should be in relatively stable condition without need for intravenous inotropic therapy 1
- Patient should not have signs of marked fluid retention 1
- Most patients can be managed as outpatients during titration 1
Monitoring During Titration
- Monitor for heart failure symptoms, fluid retention, hypotension, and bradycardia 1
- Check blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 1
- Monitor heart rate, blood pressure, clinical status, symptoms, signs of congestion, and body weight 1
Managing Common Issues During Titration
- If symptoms worsen: First increase dose of diuretics or ACE inhibitor; temporarily reduce beta-blocker dose if necessary 1
- If hypotension occurs: First reduce dose of vasodilators; reduce beta-blocker dose if necessary 1
- If bradycardia occurs: Reduce or discontinue other heart rate-lowering drugs; reduce beta-blocker dose if necessary, but discontinue only if clearly required 1
- Always attempt to reintroduce and uptitrate beta-blocker when patient becomes stable 1
Importance of Achieving Target Dose
- Studies show a dose-response relationship with improved outcomes 1, 2
- 63% of patients can achieve the maximum target dose of 10 mg daily 3
- Even if target dose cannot be reached, any dose of bisoprolol is beneficial for reducing mortality 4
- The mean achieved dose in clinical practice is often around 5-8.5 mg daily 3, 2
- Efforts should be made to maintain bisoprolol therapy at the highest tolerated dose 4
Special Populations
- Renal or hepatic impairment: Initial daily dose should be 2.5 mg with caution in dose titration 5
- Elderly patients: No dose adjustment needed unless significant renal or hepatic dysfunction is present 5
- Severe heart failure (NYHA Class III/IV): These patients should be referred for specialist care during initiation 1
Contraindications
- Asthma or severe bronchial disease 1
- Symptomatic bradycardia or hypotension 1
- Second or third-degree AV block without pacemaker 1
Clinical Outcomes
- Bisoprolol reduces all-cause mortality by approximately 34% in heart failure patients 6
- Sudden death is reduced by approximately 44% with bisoprolol therapy 6
- Benefits are seen across all tolerated dose levels, but higher doses may provide additional benefits in terms of left ventricular function and remodeling 2, 4
- Treatment withdrawal is associated with increased mortality risk (RH=2.13) 4