What is the recommended dosage of bisoprolol for adults with hypertension or heart failure, considering factors such as age and impaired renal function?

Bisoprolol Dosing Recommendations

For hypertension, start bisoprolol at 5 mg once daily (or 2.5 mg in patients with bronchospastic disease), titrating to 10 mg and then 20 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 dose of 10 mg once daily. 1, 2

Dosing by Indication

Hypertension

• The FDA-approved starting dose is 5 mg once daily, with dose escalation to 10 mg and then 20 mg once daily if blood pressure control is inadequate 1
• For patients with bronchospastic disease, initiate at 2.5 mg once daily 1
• The American College of Cardiology notes that beta-blockers are not first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 2

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Start at 1.25 mg once daily and double the dose every 2 weeks as tolerated, targeting 10 mg once daily 2, 3
• The titration schedule follows: 1.25 mg → 2.5 mg → 5 mg → 10 mg once daily 2
• The European Society of Cardiology emphasizes that bisoprolol is one of only three beta-blockers proven to reduce mortality in HFrEF (34% relative risk reduction), making this a class effect specific to bisoprolol, carvedilol, and metoprolol succinate 2, 3
• Even if the target dose of 10 mg cannot be achieved, maintaining at least 50% of target dose (5 mg daily minimum) provides mortality benefit 2
• Monitor heart rate, blood pressure, clinical status, and signs of congestion at each visit during titration 2

Special Populations

Renal Impairment

• For mild to moderate renal dysfunction, no dose adjustment is necessary 1, 4
• For severe renal impairment (creatinine clearance <40 mL/min) or end-stage renal disease, start at 2.5 mg once daily and do not exceed 10 mg once daily 1, 4, 5
• Bisoprolol has balanced clearance (both renal and hepatic), preventing accumulation beyond a factor of 2 even in complete renal failure 4, 5
• The elimination half-life increases by a factor of 1.96 in severe renal dysfunction (from 10 hours to 18.5-24.2 hours) 4, 5
• Bisoprolol is not dialyzable, so drug replacement is not necessary in patients undergoing dialysis 1, 4

Hepatic Impairment

• For hepatitis or cirrhosis, start at 2.5 mg once daily and use caution during dose titration 1, 5
• In liver cirrhosis, the elimination half-life increases to 13.5 hours and total body clearance decreases to 10.8 L/h, but accumulation does not exceed a factor of 2 5
• In terminal stages of liver insufficiency, do not exceed 10 mg daily 5

Elderly Patients

• No dose adjustment is necessary in elderly patients unless significant renal or hepatic dysfunction is present 1
• Start at the lowest possible dose (1.25 mg/day for heart failure) and increase very progressively, with stages longer than 15 days if necessary 6
• Age, eGFR, and bisoprolol dose are independent predictors of high plasma concentration 7
• High bisoprolol plasma concentration (≥5.38 ng/mL) is independently associated with worsening heart failure in elderly patients (HR 6.32,95% CI 1.34-29.83) 7
• The SENIORS study confirmed that bisoprolol is both efficacious and well-tolerated in elderly people with heart failure regardless of ejection fraction 6

Titration Protocol for Heart Failure

Initiation Requirements

• Patients must be in stable NYHA class II or III, at least 1 month after any decompensation 6
• Ensure background ACE inhibitor or ARB therapy is established before initiating beta-blocker 2
• Bisoprolol is contraindicated in current or recent (within 4 weeks) exacerbation of heart failure requiring hospitalization 2

Dose Escalation Schedule

• Double the dose at intervals of not less than 2 weeks, aiming for target doses used in clinical trials (10 mg daily) or the highest tolerated dose 2
• Monitor heart rate, blood pressure, clinical status, and signs of congestion at each visit 2
• Check blood chemistry 1-2 weeks after initiation and 1-2 weeks after final dose titration 2

Managing Adverse Effects During Titration

For worsening congestion:

• First, double the dose of diuretic 2
• Second, halve the dose of bisoprolol only if increasing diuretic does not work 2

For marked fatigue or bradycardia:

• Halve the dose of bisoprolol 2

For heart rate <50 beats/min with worsening symptoms:

• Halve the dose or stop bisoprolol if severe deterioration occurs 2

For symptomatic hypotension:

• First reconsider need for nitrates, calcium channel blockers, and other vasodilators—reduce or eliminate these before adjusting bisoprolol 2
• If no signs of congestion, consider reducing diuretic dose 2
• Only as a last resort, temporarily reduce bisoprolol dose by 50% 2

Critical Contraindications

• Decompensated heart failure or current/recent (within 4 weeks) exacerbation requiring hospitalization 2, 6
• Second or third-degree heart block, sick sinus syndrome without a permanent pacemaker 2
• Sinus bradycardia <50 beats/min 2
• Active asthma or severe reactive airway disease 2, 1
• Symptomatic bradycardia or hypotension 2

Important Clinical Pearls

• Never stop bisoprolol abruptly unless absolutely necessary, as this risks rebound ischemia, myocardial infarction, and arrhythmias 2, 3
• If discontinuation is necessary, taper gradually over about one week under close surveillance 2
• Bisoprolol offers once-daily dosing and consistent 24-hour beta-blockade, which may improve compliance compared to twice-daily formulations 2, 3
• In the CIBIS-II trial, treatment with bisoprolol at target doses of 10 mg/day was associated with significant mortality reduction 2
• Some beta-blocker is better than no beta-blocker when target doses cannot be achieved 2
• For patients with bronchospastic airway disease requiring a beta-blocker, bisoprolol (a cardioselective agent) is preferred over non-selective agents 2