What is the initial dosage and titration schedule for Bystolic (nebivolol) in a patient with hypertension?

Bystolic (Nebivolol) Dosing for Hypertension

Initial Dosage

Start nebivolol at 5 mg once daily for most patients with hypertension, taken with or without food, as either monotherapy or in combination with other antihypertensive agents. 1

• This 5 mg starting dose is the FDA-approved initial dose and has been validated in multiple clinical trials as effective for blood pressure reduction 1, 2, 3
• Nebivolol can be administered at any time of day, as it is a long-acting, once-daily formulation 1, 4

Titration Schedule

If blood pressure remains inadequately controlled, increase the dose at 2-week intervals up to a maximum of 40 mg once daily. 1

• The FDA label explicitly states that more frequent dosing intervals than every 2 weeks are unlikely to provide additional benefit 1
• Typical titration steps are: 5 mg → 10 mg → 20 mg → 40 mg, each maintained for at least 2 weeks before advancing 1
• Response rates with 5 mg nebivolol range from 58-92% in clinical trials, meaning many patients achieve adequate control without dose escalation 2, 4

Special Population Adjustments

Severe Renal Impairment (CrCl <30 mL/min)

• Start at 2.5 mg once daily and titrate slowly as needed 1
• Nebivolol has not been studied in dialysis patients 1

Moderate Hepatic Impairment

• Start at 2.5 mg once daily and titrate slowly as needed 1
• Nebivolol is contraindicated in severe hepatic impairment due to lack of safety data 1

Elderly Patients

• No dose adjustment necessary; use standard 5 mg starting dose 1

CYP2D6 Poor Metabolizers

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

Clinical Context and Positioning

Beta-blockers like nebivolol are not recommended as first-line agents for uncomplicated hypertension unless the patient has compelling indications such as ischemic heart disease or heart failure. 5

• First-line therapy for most patients should be ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 5
• Nebivolol is distinguished from other beta-blockers by its cardioselectivity and nitric oxide-mediated vasodilatory effects, which may provide advantages in tolerability 5, 2, 4
• When beta-blockade is indicated, nebivolol is preferred in patients with bronchospastic airway disease due to its beta-1 selectivity 5

Combination Therapy Considerations

• Nebivolol can be combined with thiazide diuretics for additive blood pressure reduction 4
• When used in combination therapy, the same starting dose of 5 mg once daily is appropriate 1
• Avoid abrupt cessation of nebivolol, as with all beta-blockers, to prevent rebound hypertension or cardiac events 5

Monitoring and Expected Response

• Reassess blood pressure within 2-4 weeks after initiating therapy or dose adjustments 5
• Target blood pressure is <130/80 mmHg for most adults 5, 6
• Clinical trials demonstrate that nebivolol 5 mg produces mean reductions of approximately 15-16 mmHg systolic and 10-16 mmHg diastolic blood pressure 2, 3

Common Pitfalls to Avoid

• Do not titrate more frequently than every 2 weeks, as this provides no additional benefit and may increase adverse effects 1
• Do not use nebivolol as first-line monotherapy in uncomplicated hypertension without compelling indications for beta-blockade 5
• Do not abruptly discontinue nebivolol; taper gradually to avoid withdrawal phenomena 5
• Do not forget to reduce the starting dose to 2.5 mg in patients with severe renal or moderate hepatic impairment 1