What is the recommended dosage and usage of Bisoprolol (beta-blocker) for patients with heart failure or hypertension?

Bisoprolol Dosing and Usage

Heart Failure with Reduced Ejection Fraction (HFrEF)

For HFrEF, start bisoprolol at 1.25 mg once daily and titrate every 1-2 weeks to a target dose of 10 mg once daily, as this regimen has demonstrated a 34% mortality reduction in landmark trials. 1, 2

Starting Dose and Titration Protocol

• Begin at 1.25 mg once daily in all HFrEF patients who are clinically stable and not requiring intravenous inotropic support 1, 2
• Follow this specific titration schedule with at least 1-2 weeks between increases: 1.25 mg → 2.5 mg → 3.75 mg → 5 mg → 7.5 mg → 10 mg daily 2
• The target dose is 10 mg once daily, which was the dose proven to reduce mortality in the CIBIS-II trial 1, 2, 3
• Patients must be on background ACE inhibitor therapy (unless contraindicated) before initiating bisoprolol 2

Evidence for Mortality Benefit

• Bisoprolol at target doses reduces all-cause mortality by 34% compared to placebo in patients with NYHA class III-IV heart failure 1, 3
• The CIBIS-II trial demonstrated mortality reduction regardless of heart failure etiology or severity 3
• Even if target dose cannot be achieved, maintaining the highest tolerated dose provides benefit - some bisoprolol is better than no bisoprolol 1, 4
• Mortality reduction occurs at all dose levels: low dose (1.25-3.75 mg) showed 34% reduction, moderate dose (5-7.5 mg) showed 67% reduction, and high dose (10 mg) showed 41% reduction 4

Monitoring During Titration

• Check heart rate, blood pressure, clinical status, and signs of congestion at each titration visit 1
• Obtain blood chemistry at 12 weeks after initiation and 12 weeks after reaching final dose 1
• Instruct patients to weigh themselves daily and increase diuretic if weight increases by 1.5-2 kg over 2 days 2

Managing Adverse Effects During Titration

• For worsening congestion: Double the diuretic dose first; if ineffective, halve the bisoprolol dose 1, 2
• For marked fatigue or bradycardia: Halve the bisoprolol dose 1
• For heart rate <50 bpm with worsening symptoms: Halve the dose or stop if severe deterioration occurs 1, 2
• For symptomatic hypotension: Reduce or stop other antihypertensive medications (nitrates, calcium channel blockers) before reducing bisoprolol 5

Contraindications in Heart Failure

• Current or recent (within 4 weeks) decompensated heart failure requiring hospitalization 2
• Asthma or severe bronchospastic disease 2
• Second or third-degree AV block without pacemaker 2
• Symptomatic bradycardia (<50 bpm) or hypotension 2
• Sick sinus syndrome without permanent pacemaker 2

Hypertension

For hypertension, bisoprolol is not a first-line agent unless the patient has coexisting ischemic heart disease or heart failure; when used, start at 5 mg once daily (or 2.5 mg in patients with bronchospastic disease) and titrate to 10 mg daily as needed. 6, 7

Dosing for Hypertension

• Usual starting dose: 5 mg once daily 6, 7
• Alternative starting dose: 2.5 mg once daily for patients with bronchospastic airway disease or hepatic/renal impairment 6, 7
• If 5 mg is inadequate, increase to 10 mg once daily, then if necessary to 20 mg once daily 7
• Bisoprolol is cardioselective and preferred over non-selective beta blockers in patients with reactive airways disease requiring beta blocker therapy 6

Special Populations

• Renal impairment (creatinine clearance <40 mL/min): Start at 2.5 mg daily and use caution during titration 7
• Hepatic impairment (hepatitis or cirrhosis): Start at 2.5 mg daily and use caution during titration 7
• Elderly patients: No dose adjustment necessary unless significant renal or hepatic dysfunction exists 7
• Dialysis patients: Bisoprolol is not dialyzable, so no dose replacement needed after dialysis 7

Critical Clinical Pearls

• Never abruptly discontinue bisoprolol - this can precipitate rebound hypertension, worsening ischemia, or heart failure decompensation 6, 2
• Only three beta blockers (bisoprolol, carvedilol, metoprolol succinate) have proven mortality reduction in heart failure - this is not a class effect 1
• Withdrawal of bisoprolol in heart failure patients increases mortality risk by 2.13-fold 4
• In elderly heart failure patients, use even longer titration intervals (>15 days between increases) due to higher risk of adverse effects 5
• For patients on bisoprolol requiring emergency anaphylaxis treatment, consider glucagon 1-5 mg IV as epinephrine may be less effective 1