Cardiorenal Syndrome / Hypertension in CKD Pregnancy: Bisoprolol has pharmacological effects that may cause harmful effects on pregnancy and/or the fetus/newborn. Beta-adrenoceptor blockers in general reduce placental perfusion, which has been associated with growth retardation, intrauterine death, abortion or early labour, and adverse effects (e.g. hypoglycaemia and bradycardia) may occur in the fetus and newborn. If a beta-blocker is necessary, beta-1-selective agents are preferable. Bisoprolol should NOT be used during pregnancy unless clearly necessary; if considered necessary, uteroplacental blood flow and fetal growth should be monitored, alternative treatment considered in case of harmful effects, and the newborn closely monitored (symptoms of hypoglycaemia and bradycardia are generally to be expected within the first 3 days). Breast-feeding: it is not known whether bisoprolol is excreted in human milk, therefore breast-feeding is not recommended during administration.

Bisoprolol (Cardiorenal Syndrome / CKD)

Brand names: Cardicor, Emcor

This entry covers bisoprolol in cardiorenal syndrome and CKD, a cardioselective beta-1-adrenergic blocker used for heart failure with reduced ejection fraction, angina and rate control in patients with coexisting kidney disease.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Stable chronic heart failure — titration phase: 1.25 mg once daily for 1 week; if well tolerated increase to 2.5 mg once daily for a further week; if well tolerated increase to 3.75 mg once daily for a further week; if well tolerated increase to 5 mg once daily for the 4 following weeks; if well tolerated increase to 7.5 mg once daily for the 4 following weeks; if well tolerated increase to 10 mg once daily for maintenance therapy.

Route: Oral

Frequency: Once daily, taken in the morning; can be taken with food. The orodispersible tablet is placed on the tongue and allowed to disintegrate before swallowing with or without water — it should not be chewed.

Max: 10 mg once daily (the maximum recommended dose)

Source: UK SPC (eMC) for Bisoprolol 1.25 mg Orodispersible Tablets, §4.2 (https://www.medicines.org.uk/emc/product/102393/smpc). This SPC is a CHRONIC HEART FAILURE product and its §4.2 covers that indication only — it contains NO hypertension or angina posology, so if this page is used for hypertension in CKD the regimen must be taken from a bisoprolol product SPC that carries that indication. INITIATION CONDITIONS: standard treatment of CHF consists of an ACE inhibitor (or an angiotensin receptor blocker in case of ACE-inhibitor intolerance), a beta-blocker, diuretics and, when appropriate, cardiac glycosides; patients should be STABLE (without acute failure) when bisoprolol is initiated, and it is recommended that the treating physician be experienced in the management of chronic heart failure. Transient worsening of heart failure, hypotension or bradycardia may occur during the titration period and thereafter, and close monitoring of vital signs (heart rate, blood pressure) and symptoms of worsening heart failure is recommended during titration — symptoms may occur within the first day of therapy. TREATMENT MODIFICATION: if the maximum recommended dose is not well tolerated, gradual dose reduction may be considered; in case of transient worsening of heart failure, hypotension or bradycardia, reconsider the dosage of concomitant medication and, if necessary, temporarily lower the bisoprolol dose or consider discontinuation, reintroducing and/or uptitrating once the patient is stable again. DISCONTINUATION: gradual dose decrease is recommended since abrupt withdrawal may lead to acute deterioration; especially in patients with ischaemic heart disease cessation must not be abrupt unless clearly indicated. Treatment is generally long-term. OLDER PEOPLE: no dosage adjustment is required. PAEDIATRIC: there is NO paediatric experience with bisoprolol, therefore its use cannot be recommended in paediatric patients — paedDose is null; verify any under-18 use against a children's formulary. US labelling (cross-check, may differ from UK — Bisoprolol fumarate tablets, Solco Healthcare US LLC, label date 2023-06-26): for hypertension the usual starting dose is 5 mg once daily, with 2.5 mg an appropriate starting dose in some patients, increased to 10 mg and then if necessary to 20 mg once daily. NOTE ON SOURCES: eMC §4.5 was NOT captured in this bundle and no US interactions section was retrieved — the interaction entries below come from UK §4.4 only and must be verified against the full SPC. §4.4 and the US adverse-reactions section were truncated at the source-fetch limit.

Dose adjustments

Renal

UK SPC: there is NO information regarding the pharmacokinetics of bisoprolol in patients with chronic heart failure and impaired hepatic or renal function; uptitration of the dose in these populations should therefore be made with ADDITIONAL CAUTION. There is no therapeutic experience of bisoprolol treatment of heart failure in patients with severely impaired renal function (or severely impaired hepatic function). US labelling (cross-check, may differ from UK): in patients with renal dysfunction (creatinine clearance less than 40 mL/min) or hepatic impairment (hepatitis or cirrhosis) the initial daily dose should be 2.5 mg with caution in dose titration; since limited data suggest bisoprolol fumarate is not dialysable, drug replacement is not necessary in patients undergoing dialysis.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Acute heart failure or episodes of heart failure decompensation requiring i.v. inotropic therapy
Cardiogenic shock
Second or third degree AV block, sick sinus syndrome, sinoatrial block, symptomatic bradycardia
Symptomatic hypotension
Severe bronchial asthma; severe forms of peripheral arterial occlusive disease or severe forms of Raynaud's syndrome
Untreated phaeochromocytoma; metabolic acidosis; hypersensitivity to bisoprolol or to any of the excipients

Side effects

Very common: bradycardia. Common: worsening of heart failure; AV-conduction disturbances (uncommon)
Common: dizziness, headache; asthenia, fatigue. Rare: syncope
Common: feeling of coldness or numbness in the extremities, hypotension; uncommon: orthostatic hypotension
Common: gastrointestinal complaints such as nausea, vomiting, diarrhoea, constipation
Uncommon: bronchospasm in patients with bronchial asthma or a history of obstructive airways disease; muscular weakness and cramps; sleep disorder, depression
Rare: hypersensitivity reactions (pruritus, flush, rash and angioedema), hepatitis, erectile dysfunction, increased triglycerides and increased liver enzymes (ALAT, ASAT), reduced tear flow, hearing disorders, nightmare, hallucination; beta-blockers may provoke or worsen psoriasis or induce a psoriasis-like rash

Interactions

Calcium antagonists of the verapamil or diltiazem type — combination with bisoprolol is generally NOT recommended (UK §4.4)
Class I antiarrhythmic drugs — combination is generally NOT recommended (UK §4.4)
Centrally acting antihypertensive drugs — combination is generally NOT recommended (UK §4.4)
General anaesthetics — the anaesthetist must be aware of beta-blockade because of the potential for interactions with other drugs, resulting in bradyarrhythmias, attenuation of reflex tachycardia and decreased reflex ability to compensate for blood loss; maintenance beta-blockade is currently recommended to be continued peri-operatively, and if withdrawal before surgery is thought necessary it should be gradual and completed about 48 hours before anaesthesia (UK §4.4)
Adrenaline/epinephrine — bisoprolol may increase both the sensitivity towards allergens and the severity of anaphylactic reactions, and epinephrine treatment does not always yield the expected therapeutic effect; caution during ongoing desensitisation therapy (UK §4.4)
eMC §4.5 was not captured in the source bundle and must be checked on the SPC

Clinical monograph

How it works

It selectively blocks beta-1-adrenoceptors, reducing heart rate, myocardial contractility and renin release, which improves outcomes in chronic heart failure when titrated slowly.

Prescribing in practice

In heart failure it must be started at a low dose and uptitrated gradually when the patient is stable, as abrupt initiation or withdrawal can precipitate decompensation.
Bisoprolol is partly renally cleared, so cautious dosing is appropriate in significant renal impairment, watching for bradycardia and hypotension.
Use caution combining with other rate-limiting agents and monitor potassium when used alongside renin-angiotensin and aldosterone blockade common in cardiorenal disease.

Monitoring

Monitor heart rate, blood pressure, fluid status and renal function, particularly during dose titration.

Counselling the patient

Do not stop the tablets suddenly; any reduction should be gradual and supervised.
Report marked dizziness, a very slow pulse or worsening breathlessness or swelling.
Initial tiredness often improves as your body adjusts.

Evidence & guidelines

Gradual beta-blocker titration in heart failure with reduced ejection fraction is supported by the CIBIS-II trial and NICE chronic heart failure guidance.

Reference: CIBIS-II Trial (Lancet 1999); NICE NG106 (Chronic Heart Failure); NICE NG136 (Hypertension); SPC Cardicor; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways