What is the average dose of Bystolic (nebivolol) for treating hypertension?

Average Dose of Bystolic (Nebivolol) for Hypertension

The standard starting dose of Bystolic (nebivolol) is 5 mg once daily, which can be titrated up to a maximum of 40 mg daily at 2-week intervals if additional blood pressure reduction is needed. 1

Standard Dosing Protocol

• Initial dose: 5 mg once daily (with or without food), either as monotherapy or in combination with other antihypertensive agents 1
• Titration schedule: Increase at 2-week intervals if blood pressure targets are not achieved 1
• Maximum dose: 40 mg once daily 1
• More frequent dosing intervals are unlikely to provide additional benefit 1

Clinical Efficacy at Standard Dose

The 5 mg once daily dose is therapeutically effective and well-established:

• Response rates of 58-81% have been documented with nebivolol 5 mg once daily after 4-52 weeks of treatment 2
• The 5 mg dose produces mean reductions in diastolic blood pressure of approximately 7.8 mm Hg compared to placebo 3
• Nebivolol 5 mg is therapeutically equivalent to metoprolol 50 mg once daily 4
• At 5 mg daily, nebivolol demonstrates comparable efficacy to atenolol 50 mg, lisinopril, and nifedipine 2, 5

Dose-Response Relationship

Higher doses provide incrementally greater blood pressure reduction:

• 5 mg dose: -7.8 mm Hg reduction in diastolic BP 3
• 10 mg dose: -8.5 mm Hg reduction in diastolic BP 3
• 20 mg dose: -9.1 mm Hg reduction in diastolic BP (with statistically significant systolic BP reduction) 3

The 5 mg and 10 mg doses maintain tolerability comparable to placebo, while the 20 mg dose shows increased efficacy with acceptable safety 3.

Special Population Adjustments

Renal impairment (CrCl <30 mL/min):

• Start at 2.5 mg once daily and titrate slowly as needed 1
• Not studied in dialysis patients 1

Hepatic impairment (moderate):

• Start at 2.5 mg once daily and titrate slowly as needed 1
• Contraindicated in severe hepatic impairment 1

Elderly patients:

• No dose adjustment necessary; standard 5 mg starting dose is appropriate 1

CYP2D6 poor metabolizers:

• No dose adjustment required; clinical effects are similar to extensive metabolizers 1

Combination Therapy Considerations

• Nebivolol demonstrates additive effects when combined with hydrochlorothiazide 2
• In comparative studies, fewer nebivolol patients required addition of diuretics compared to atenolol 6
• Beta-blockers like nebivolol are not first-line agents unless the patient has ischemic heart disease or heart failure; preferred first-line treatments include ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics 7

Practical Clinical Pearls

• Once-daily dosing promotes adherence and maintains 24-hour blood pressure control 1, 2
• Nebivolol produces less impact on augmentation index compared to atenolol, suggesting better arterial compliance 6
• The drug is well-tolerated with adverse events (headache, fatigue, paresthesias, dizziness) being infrequent, transient, and mild to moderate 2
• No orthostatic hypotension has been reported in multiple studies 2, 5
• Unlike some beta-blockers, nebivolol does not significantly affect sexual function 2