What is the maximum recommended dose of Concor (bisoprolol) for a patient with hypertension or heart failure?

Maximum Dose of Concor (Bisoprolol)

The maximum recommended dose of Concor (bisoprolol) is 10 mg once daily for heart failure with reduced ejection fraction (HFrEF), and 20 mg once daily for hypertension, though doses above 10 mg provide limited additional benefit. 1, 2

Heart Failure Dosing

• For HFrEF, the target dose is 10 mg once daily, which was the dose proven to reduce mortality by 34% in the landmark CIBIS-II trial 1
• The European Society of Cardiology recommends starting at 1.25 mg once daily and doubling the dose every 2-4 weeks as tolerated until reaching the target of 10 mg daily 1
• The titration schedule follows: 1.25 mg → 2.5 mg → 5 mg → 10 mg once daily 1
• Even if the full 10 mg target cannot be achieved, maintaining at least 50% of target dose (5 mg daily minimum) provides mortality benefit, as dose-response relationships exist 1

Hypertension Dosing

• The FDA label states that for hypertension, the usual starting dose is 5 mg once daily, which may be increased to 10 mg and then to a maximum of 20 mg once daily if needed 2
• However, clinical evidence suggests that 5-10 mg daily is effective for most patients with stage I-II hypertension, with 80.9% of patients achieving good blood pressure control at these doses 3

Special Populations Requiring Dose Adjustment

• In patients with hepatic impairment (hepatitis or cirrhosis) or renal dysfunction (creatinine clearance <40 mL/min), the initial dose should be 2.5 mg daily with cautious titration, and the maximum dose should not exceed 10 mg daily 2, 4
• In terminal stages of kidney or liver insufficiency, bisoprolol dosage should not exceed 10 mg daily due to prolonged elimination half-life (up to 24.2 hours in uraemic patients versus 10 hours in healthy subjects) 4
• Bisoprolol is not dialyzable, so dose replacement is not necessary in patients undergoing dialysis 2
• No dose adjustment is necessary in elderly patients unless significant renal or hepatic dysfunction is present 2

Critical Monitoring Parameters

• Monitor heart rate (target >50 bpm without symptoms), blood pressure, clinical status, and signs of congestion at each visit 1
• For heart rate <50 bpm with worsening symptoms, halve the bisoprolol dose 1
• Check blood chemistry 1-2 weeks after initiation and 1-2 weeks after final dose titration 1
• Patients should weigh themselves daily and increase diuretic dose if weight increases by 1.5-2.0 kg over 2 consecutive days 1

Common Pitfalls to Avoid

• Underdosing is the most common error in clinical practice—fewer than 25% of patients in real-world settings are titrated to target doses, compared to 64% in clinical trials 5
• Never stop bisoprolol abruptly, as this risks rebound ischemia, myocardial infarction, and ventricular arrhythmias—taper gradually over approximately one week under close surveillance 1
• Asymptomatic low blood pressure does not require dose adjustment; only symptomatic hypotension warrants intervention 1
• For worsening congestion, first double the diuretic dose and only halve bisoprolol if increasing diuretics fails 1

Contraindications to Maximum Dosing

• Current or recent (within 4 weeks) decompensated heart failure requiring hospitalization 1
• Second- or third-degree heart block, sick sinus syndrome without permanent pacemaker, or sinus bradycardia <50 bpm 1
• Active asthma with positive bronchoreactivity 1
• Severe hepatic impairment or advanced renal failure (creatinine clearance <40 mL/min) where 10 mg is the absolute maximum 2, 4