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Cardiorenal Syndrome / Hypertension in CKD Pregnancy: Use with caution — neonatal bradycardia, hypoglycaemia, intrauterine growth restriction reported; monitor neonate after delivery. Benefit outweighs risk in severe maternal cardiac disease.

Bisoprolol (Cardiorenal Syndrome / CKD)

Brand names: Cardicor, Emcor

Adult dose

Dose: Heart failure: start 1.25 mg once daily; titrate every 2 weeks to target 10 mg OD. Hypertension/angina: 5-10 mg once daily.
Route: Oral
Frequency: Once daily
Max: 20 mg/day
Cardioselective beta-1 blocker. Used in cardiorenal syndrome (CRS types 1-4), heart failure with reduced EF (HFrEF) in CKD, and hypertension. Partial renal excretion — dose reduce in severe renal impairment.

Paediatric dose

Route: Oral
Seek specialist opinion — not licensed in children for heart failure

Dose adjustments

Renal

eGFR 20-50: no dose adjustment usually needed. eGFR <20: max 10 mg/day. Haemodialysis: bisoprolol not significantly removed by HD — dosing unchanged but monitor bradycardia and BP.

Hepatic

eGFR <20 + hepatic impairment: max 10 mg/day

Clinical pearls

  • Cardiorenal syndrome: bisoprolol is cornerstone of HFrEF management even in CKD. The CIBIS-II trial (bisoprolol in HFrEF) showed 34% all-cause mortality reduction — benefit holds in CKD subgroups, though uptitration may be slower.
  • Initiation in acute decompensation: never start bisoprolol in acutely decompensated heart failure requiring IV diuretics — wait until patient is euvolaemic. In stable CKD + HFrEF, slow uptitration is safe.
  • Withdrawal: NEVER stop bisoprolol abruptly — rebound tachycardia, hypertension, and angina/MI risk. Taper over minimum 1-2 weeks.
  • Beta-blockers in CKD + anaemia (EPO-treated): EPO causes increased blood viscosity and hypertension; beta-blockade helps control EPO-related hypertension. Monitor BP closely after EPO dose changes.
  • Bisoprolol vs carvedilol in CKD: bisoprolol is hydrophilic and partially renally excreted; carvedilol is lipophilic and hepatically metabolised (no renal dose adjustment needed). Carvedilol may be preferred in severe CKD for this reason, though both are guideline-recommended in HFrEF.

Contraindications

  • Cardiogenic shock
  • Decompensated heart failure requiring IV inotropes
  • Severe bradycardia (HR <50 bpm)
  • Sick sinus syndrome
  • 2nd/3rd degree AV block
  • Severe bronchospasm or obstructive airways disease (relative — use with extreme caution)

Side effects

  • Bradycardia
  • Fatigue/lethargy
  • Cold extremities
  • Hypotension
  • Bronchospasm (less with cardioselective agents but not zero)
  • Masking of hypoglycaemia (except sweating)
  • Worsening of peripheral arterial disease
  • Sexual dysfunction

Interactions

  • Non-dihydropyridine calcium antagonists (verapamil, diltiazem) — additive bradycardia and AV block; potentially fatal combination
  • Anti-arrhythmics (amiodarone, flecainide) — additive bradycardia
  • Clonidine — rebound hypertension if bisoprolol stopped first; withdraw bisoprolol before clonidine
  • Insulin/antidiabetics — hypoglycaemia symptoms masked (except sweating)

Monitoring

  • Heart rate (target 50-60 bpm in HFrEF)
  • Blood pressure
  • eGFR and fluid status
  • Signs of decompensation (dyspnoea, oedema)
  • ECG (AV conduction)

Reference: BNFc; BNF 90; CIBIS-II Trial (Lancet 1999); NICE NG106 (Chronic Heart Failure); NICE NG136 (Hypertension); SPC Cardicor. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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