Switching from Metoprolol to Bisoprolol
Switch directly from metoprolol to bisoprolol without a washout period, using equivalent dosing based on the indication, and monitor closely for the first 2-4 weeks.
Dose Equivalence and Conversion Protocol
For Heart Failure with Reduced Ejection Fraction (HFrEF)
The most straightforward approach is to discontinue metoprolol 12 hours before starting bisoprolol, then initiate bisoprolol at an equivalent or lower dose. 1
- Metoprolol succinate 25 mg daily → Bisoprolol 2.5 mg daily
- Metoprolol succinate 50 mg daily → Bisoprolol 5 mg daily
- Metoprolol succinate 100 mg daily → Bisoprolol 7.5-10 mg daily
- Metoprolol succinate 200 mg daily → Bisoprolol 10 mg daily 2
The target dose for bisoprolol in HFrEF is 10 mg once daily, while metoprolol succinate targets 200 mg once daily, suggesting approximately a 20:1 ratio. 2
For Hypertension
- Metoprolol tartrate 100-200 mg daily → Bisoprolol 5-10 mg daily
- Both agents are dosed once daily for hypertension, though metoprolol tartrate may require twice-daily dosing. 2
Step-by-Step Switching Protocol
Immediate Switch Method (Preferred)
- Discontinue metoprolol 12 hours before the first dose of bisoprolol 1
- Start bisoprolol at the equivalent dose or one step lower if concerned about tolerability 1
- Monitor heart rate and blood pressure within 24-48 hours of the switch 2
- Assess for signs of decompensation, bradycardia (<50 bpm), or hypotension at 1-2 weeks 2
Titration After Switch
- Double the bisoprolol dose every 2-4 weeks as tolerated until reaching the target dose of 10 mg daily 2
- In the study of 282 patients switching from metoprolol tartrate to bisoprolol, only 28.5% reached the 10 mg target dose, with mean heart rate dropping from 84 bpm to 67 bpm, indicating more effective adrenergic blockade. 1
Critical Monitoring Parameters
First 2 Weeks Post-Switch
- Heart rate: Hold or reduce dose if <50 bpm with worsening symptoms 2
- Blood pressure: Adjust other antihypertensives if symptomatic hypotension occurs 2
- Signs of heart failure decompensation: Daily weights, increased dyspnea, edema 2
- Blood chemistry at 12 weeks after final dose titration 2
Red Flags Requiring Dose Adjustment
- Heart rate <50 bpm with symptoms → Halve bisoprolol dose 2
- Worsening congestion → Double diuretic dose and/or halve bisoprolol dose 2
- Marked fatigue or bradycardia → Halve bisoprolol dose 2
Rationale for Switching
Both bisoprolol and metoprolol succinate are guideline-recommended beta-blockers with proven mortality reduction in HFrEF (34% relative risk reduction), but bisoprolol offers once-daily dosing and may provide more consistent beta-blockade. 3, 2
The switch from short-acting metoprolol tartrate to long-acting bisoprolol is particularly beneficial, as only long-acting beta-blockers have demonstrated survival benefits in clinical trials. 1
Common Pitfalls to Avoid
Do Not Abruptly Stop Metoprolol Without Starting Bisoprolol
- Abrupt beta-blocker cessation can cause rebound hypertension, worsening ischemia, or arrhythmias. 2, 4
- Withdrawal phenomena including headache, palpitations, and tremor occurred in 67% of patients after propranolol and 38% after metoprolol in one study. 4
Do Not Use a Prolonged Washout Period
- A 12-hour gap is sufficient and safer than extended washout periods. 1
- Beta-adrenergic sensitivity rebounds 2-8 days after metoprolol withdrawal, creating a vulnerable period. 4
Do Not Underdose
- Many clinicians maintain patients on suboptimal doses due to fear of side effects. 2
- Even if target doses cannot be achieved, some beta-blocker is better than no beta-blocker. 2
- Aim for at least 50% of target dose (bisoprolol 5 mg daily minimum) to achieve mortality benefits. 3
Special Considerations
Contraindications to Verify Before Switching
- Asthma or severe bronchospastic disease 2
- Second- or third-degree heart block without pacemaker 2
- Sinus bradycardia <50 bpm 2
- Current decompensated heart failure (NYHA Class IV or recent hospitalization within 4 weeks) 2