What is the recommended dosage of Bisoprolol (beta blocker) for adults with hypertension or heart failure?

Bisoprolol Dosage Recommendations

For hypertension, start bisoprolol at 5 mg once daily (or 2.5 mg in patients with bronchospastic disease or hepatic/renal impairment), titrating to 10 mg once daily if needed; for heart failure with reduced ejection fraction, start at 1.25 mg once daily and titrate every 2 weeks to a target of 10 mg once daily. 1, 2

Hypertension Dosing

Starting dose: 5 mg once daily is the standard initial dose for most patients with hypertension 1. However, 2.5 mg once daily should be used as the starting dose in patients with bronchospastic disease 1.

Titration schedule: If blood pressure control is inadequate with 5 mg, increase to 10 mg once daily, and if necessary, to a maximum of 20 mg once daily 1. The antihypertensive effect is dose-dependent, with 20 mg demonstrating significantly greater efficacy than lower doses 3.

Target blood pressure: Aim for <130/80 mmHg for most patients 2.

Important considerations for hypertension:

• Beta-blockers like bisoprolol are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 2
• Most patients achieve adequate blood pressure control with 5-10 mg once daily as monotherapy 4
• The once-daily dosing provides 24-hour blood pressure control due to bisoprolol's 10-12 hour half-life 3

Heart Failure with Reduced Ejection Fraction (HFrEF) Dosing

Starting dose: 1.25 mg once daily for all patients with stable compensated heart failure 2, 5.

Titration protocol:

• Double the dose every 2 weeks (minimum interval) if the previous dose is well tolerated 2
• Progression: 1.25 mg → 2.5 mg → 5 mg → 7.5 mg → 10 mg once daily 2, 5
• In elderly patients, stages longer than 2 weeks may be necessary 5

Target dose: 10 mg once daily, which demonstrated a 32% reduction in all-cause mortality in the CIBIS-II trial 6, 2.

Critical point: Even if the target dose cannot be achieved, maintain the highest tolerated dose—some bisoprolol is better than no bisoprolol, with mortality benefits seen even at lower doses 2.

Prerequisites before initiating bisoprolol in heart failure:

• Patient must be in stable NYHA class II or III (not currently decompensated) 5
• At least 1 month after any decompensation episode 5
• Background ACE inhibitor or ARB therapy should be established 2
• Bisoprolol is contraindicated in current or recent (within 4 weeks) heart failure exacerbation requiring hospitalization 2

Monitoring during titration:

• Heart rate: Target >50 bpm; if <50 bpm with worsening symptoms, halve the dose 2
• Blood pressure: Monitor for symptomatic hypotension 2
• Clinical status: Watch for signs of congestion and body weight changes 2
• Blood chemistry: Check 12 weeks after initiation and 12 weeks after final dose titration 2

Managing adverse effects during titration:

For worsening congestion:

1. First, double the diuretic dose 2
2. Second, halve the bisoprolol dose only if increasing diuretic fails 2

For marked fatigue or bradycardia:

• Halve the bisoprolol dose 2

For symptomatic hypotension:

1. First, reduce or eliminate vasodilators (nitrates, calcium channel blockers) 5
2. Second, reduce diuretic dose if no signs of congestion 5
3. Third, reduce bisoprolol dose only if above measures fail 5

Special Populations

Renal or hepatic impairment: Start at 2.5 mg once daily and use caution during dose titration 1. Bisoprolol is not dialyzable, so dose replacement is unnecessary in dialysis patients 1.

Elderly patients: No dose adjustment is necessary unless significant renal or hepatic dysfunction is present 1. However, in elderly heart failure patients, use the lowest starting dose (1.25 mg daily) and titrate more slowly with stages longer than 2 weeks if needed 5.

Pediatric patients: No pediatric experience exists with bisoprolol 1.

Absolute Contraindications

• Second or third-degree heart block without a permanent pacemaker 2
• Sick sinus syndrome without a permanent pacemaker 2
• Active asthma or severe bronchospasm 2
• Sinus bradycardia <50 bpm 2
• Current or recent (within 4 weeks) decompensated heart failure requiring hospitalization 2

Critical Pitfalls to Avoid

Never abruptly discontinue bisoprolol unless absolutely necessary, as this risks rebound ischemia, infarction, and arrhythmias 2. If discontinuation is required, taper gradually.

Underdosing is common: Many clinicians maintain patients on suboptimal doses due to fear of side effects or clinical inertia 2. The target dose of 10 mg daily has proven mortality benefits in clinical trials, and achieving at least 50% of the target dose (5 mg daily minimum) is crucial 2.

Don't abandon therapy prematurely: Transient worsening during up-titration can often be managed by adjusting other medications (diuretics, vasodilators) rather than stopping bisoprolol 2, 5.