Bisoprolol Dosing in End-Stage Renal Disease on Dialysis
For patients with ESRD on dialysis, bisoprolol should be started at 2.5 mg once daily, with a maximum dose not exceeding 10 mg once daily. 1, 2
Starting Dose and Titration
- Initial dose: 2.5 mg once daily for patients with creatinine clearance <40 mL/min or those on dialysis 1
- The standard starting dose of 5 mg used in patients with normal renal function should be reduced by half in ESRD 1
- Dose titration should proceed cautiously, monitoring for symptomatic hypotension, excessive bradycardia (heart rate <50 bpm), or signs of worsening heart failure 3
- Maximum dose: 10 mg once daily in severe or end-stage renal failure 1, 2
Rationale for Dose Adjustment
Bisoprolol has balanced clearance through both renal (50%) and hepatic (50%) pathways, which prevents excessive accumulation even in complete renal failure 2. However, the elimination half-life increases by a factor of 1.96 in severe renal dysfunction 2. Pharmacokinetic studies demonstrate that 48-hour plasma levels in dialysis patients are similar to those with severe renal dysfunction, suggesting accumulation is unlikely to exceed a factor of 2 at steady state 2.
Dialysis Considerations
- Drug replacement after dialysis is NOT necessary - bisoprolol is not significantly removed by hemodialysis 1
- Dosing can be given at any time relative to dialysis sessions, as dialysis does not meaningfully clear the drug 1
- The medication can be administered once daily regardless of dialysis schedule 1
Clinical Monitoring
Monitor the following parameters during bisoprolol therapy in ESRD patients:
- Blood pressure and heart rate at each visit during dose titration 3
- Signs of fluid overload or worsening heart failure (bisoprolol should not be initiated during acute decompensation) 3
- Serum potassium levels - nonselective beta-blockers can increase potassium, though bisoprolol is beta-1 selective and this risk is lower 4
- Symptoms of excessive beta-blockade: dizziness, fatigue, bradycardia 3
Advantages in ESRD Population
Beta-blockers, including bisoprolol, provide specific benefits in dialysis patients beyond blood pressure control 4, 5:
- Reduction in cardiovascular mortality 4
- Decreased ventricular arrhythmias 4
- Improved left ventricular function 4
- Reduction in left ventricular hypertrophy 4
Common Pitfalls to Avoid
- Do not use standard 5 mg starting dose - this is appropriate only for patients with normal renal function 1
- Do not exceed 10 mg daily even if blood pressure control is suboptimal; add additional antihypertensive agents instead 1, 2
- Do not give supplemental doses after dialysis - unlike renally-eliminated agents (lisinopril, atenolol), bisoprolol does not require post-dialysis dosing 1, 4
- Avoid initiation during acute decompensation - patients should be clinically stable before starting beta-blocker therapy 3