From the Guidelines
Bisoprolol dosing in dialysis patients typically does not require significant adjustment, with a recommended starting dose of 2.5 mg once daily, which can be gradually increased to a maximum of 10 mg daily based on clinical response and tolerability, as indicated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The dual elimination pathway of bisoprolol, with approximately 50% elimination by the kidneys and 50% by the liver, allows for adequate clearance in patients with end-stage renal disease on dialysis through hepatic metabolism, and bisoprolol is not significantly removed by hemodialysis. When treating dialysis patients, it's essential to monitor for signs of beta-blocker side effects such as bradycardia, hypotension, and worsening heart failure, especially during dose titration, and to check blood pressure before and after dialysis sessions, as fluid shifts during dialysis may affect hemodynamics. If the patient experiences significant hypotension during or after dialysis, consider administering the medication after the dialysis session rather than before, and follow the dose up-titration guidelines, which recommend visits every 2–4 weeks to up-titrate the dose of beta-blocker, without increasing the dose if signs of worsening HF, symptomatic hypotension, or excessive bradycardia are present 1. Key considerations include:
- Starting dose: 2.5 mg once daily
- Maximum dose: 10 mg daily
- Dose titration: every 2–4 weeks, without exceeding the maximum tolerated dose or target dose of 10 mg o.d.
- Monitoring: regular checks for beta-blocker side effects, blood pressure, and signs of worsening HF, symptomatic hypotension, or excessive bradycardia.
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 recommended initial dose of bisoprolol in dialysis patients is 2.5 mg once daily, and caution should be used in dose-titration.
- The dose may need to be adjusted based on the patient's response and renal function.
- No dose replacement is necessary in patients undergoing dialysis, as bisoprolol is not dialyzable 2.
From the Research
Bisoprolol Dose in Dialysis Patients
- The recommended dose of bisoprolol in dialysis patients is not universally established, but a study published in 1999 3 suggests that a daily dose of 2.5 mg may be adequate and relatively effective for patients with dialysis-refractory hypertension.
- This dose was found to be effective in reducing blood pressure and plasma renin activity in patients with hyperreninemic hypertension, while minimizing the risk of dialysis hypotension and bradycardia.
- Another study published in 2018 4 found that bisoprolol is dialyzable, with a dialytic clearance value of 44 ml/min using the recovery clearance method, and 96 ml/min using the arterial venous difference method.
- The dialyzability of bisoprolol is an important consideration in determining the optimal dose for dialysis patients, as it may affect the drug's efficacy and safety profile.
- A study published in 2020 5 found that the plasma concentration of bisoprolol is increased by renal dysfunction, which may explain the discrepancy between the dose of bisoprolol administered and its plasma concentration.
- Overall, the available evidence suggests that a daily dose of 2.5 mg bisoprolol may be a reasonable starting point for dialysis patients, but the optimal dose may vary depending on individual patient characteristics, such as renal function and severity of hypertension.
- It is also important to consider the potential benefits and risks of beta-blocker use in dialysis patients, as outlined in studies published in 2018 6 and 2018 7, which highlight the importance of evidence-based recommendations for beta-blocker use in this population.