From the Guidelines
The maximum dose of bisoprolol for dialysis patients should not exceed 10 mg once daily, as it is moderately dialyzable and requires careful dose titration to avoid adverse effects. According to the EXTRIP workgroup study published in 2021 1, bisoprolol is classified as moderately dialyzable, which means that it can be removed by dialysis to some extent. However, the study also notes that the removal of bisoprolol by dialysis is not significant enough to require a specific dose reduction for dialysis patients.
When considering the dosing of bisoprolol in dialysis patients, it's essential to start with a lower dose of 1.25-2.5 mg daily and titrate slowly based on blood pressure response and heart rate control, as recommended by clinical guidelines 1. This approach allows for careful monitoring of adverse effects such as bradycardia, hypotension, and worsening heart failure during dose titration.
Key considerations for bisoprolol dosing in dialysis patients include:
- Starting with a lower dose and titrating slowly
- Monitoring for adverse effects such as bradycardia and hypotension
- Considering the potential for drug accumulation in patients with both renal and hepatic impairment
- Being aware that bisoprolol is not significantly removed by dialysis, so the timing of administration relative to dialysis sessions is not critical.
Overall, the goal of bisoprolol dosing in dialysis patients is to achieve optimal blood pressure control while minimizing the risk of adverse effects, and this can be achieved by following a careful and individualized dosing approach 1.
From the FDA Drug Label
The dose of bisoprolol fumarate must be individualized to the needs of the patient. ... In patients with hepatic impairment (hepatitis or cirrhosis) or renal dysfunction (creatinine clearance less than 40 mL/min), the initial daily dose should be 2. 5 mg and caution should be used in dose-titration. Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.
The maximum dose of bisoprolol in a dialysis patient is 20 mg once daily, as the drug label does not specify a different maximum dose for dialysis patients, but does recommend caution in dose-titration for patients with renal dysfunction, and an initial dose of 2.5 mg in these patients 2.
From the Research
Maximum Dose of Bisoprolol in Dialysis Patients
- The maximum dose of bisoprolol in dialysis patients is not explicitly stated in most studies, but according to 3, in severe or end-stage renal failure, the dose should not exceed 10 mg once daily.
- Another study 4 investigated the efficacy and safety of bisoprolol in patients with dialysis-refractory hypertension and found that a daily dose of 2.5 mg bisoprolol seems to be an adequate and relatively effective dose.
- However, the study 4 also reported that dialysis hypotension and bradycardia occurred in two patients receiving 5.0 mg/day of bisoprolol, suggesting that higher doses may be associated with increased risk of adverse effects.
- Other studies 5, 6, 7 do not provide specific information on the maximum dose of bisoprolol in dialysis patients, but they do suggest that bisoprolol can be used safely and effectively in patients with renal dysfunction or chronic heart failure.
Key Findings
- Bisoprolol may be used safely in patients with renal dysfunction, with no adjustment of dose necessary for those with mild to moderate dysfunction 3.
- In patients with severe or end-stage renal failure, the dose should not exceed 10 mg once daily 3.
- A daily dose of 2.5 mg bisoprolol seems to be an adequate and relatively effective dose in patients with dialysis-refractory hypertension 4.