Lidocaine
Severe
Textbook-cited
Enhanced bradycardia and hypotension.
Avoid concurrent use
Source: KDT 7e · p950
Drug reference
Bisoprolol
Cardioselective beta-1 adrenergic receptor antagonist (beta-blocker) · Antihypertensive, Antiarrhythmic, Antianginal, Heart Failure Treatment, Thyrotoxicosis Management
Also known as Bisoprolol fumarate
START
Check HR (>60 bpm), BP, auscultate for wheeze. Baseline ECG. In HFrEF: start at 1.25mg and titrate slowly (every 2 weeks) while monitoring for fluid overload.
TYPICAL MAX
20mg/day (HTN); 10mg/day (HFrEF). Loss of cardioselectivity at doses >20mg.
STOP IF
HR <50 bpm, SBP <90 mmHg, new wheeze/bronchospasm, acute heart failure decompensation, second-degree AV block, syncope.
WATCH
HFrEF: may worsen symptoms initially—ensure stable fluid status before starting and during titration. Diabetics: may mask hypoglycemia. Do not stop abruptly—rebound angina/arrhythmia risk. COPD: preferred beta-blocker if indication exists (cardioselective).
CDSCO approvedSchedule HATC C07AB07
KDIGO 2024 + manufacturer label
- ONSET
- 2h · Onset 1-2 hours
- PEAK
- 3h · Tmax 2-4 hours
- t½
- 11h · t½ ~10-12 hours
- DURATION
- 1d · 24 hours (QD)
EXCRETION
Renal and fecal (~50% each)
route + CYP
INTERACTIONS
12 major
SEVERE in our sources
PREGNANCY
Crosses placenta; may cause fetal bradycardia, hypoglycemia, and growth restriction. Use lowest effective dose. Monitor newborn for 48-72h after delivery (bradycardia, hypoglycemia).
FDA category + note
Top interactionssee all 12 →
- LidocaineSevereTextbook-citedKDT 7e · p950
- AdrenalineSevereTextbookKDT 7e · p133
- AmilorideSevereTextbookKDT 7e
- SofosbuvirSevereTextbookHarrison 22e · unknown
Available in India
108 branded formulations and 3 fixed-dose combinations. Look up specific brands in the Drugs workspace.
Mechanism
Selective competitive antagonism of beta-1 adrenergic receptors in cardiac muscle, reducing heart rate, myocardial contractility, and cardiac output. At higher doses (>20mg), loses cardioselectivity and blocks beta-2 receptors.
Indications
HypertensionChronic heart failure with reduced ejection fraction (HFrEF)Chronic stable anginaSupraventricular tachyarrhythmias (rate control)Post-myocardial infarction secondary prevention
Dosing
- Adult
- Hypertension/angina: 5mg PO daily initially, may increase to 10mg daily; max 20mg daily. HFrEF: 1.25mg PO daily initially, double every 2 weeks to 2.5mg, 3.75mg, 5mg, 7.5mg, target 10mg daily (CIBIS-II target).
- Pediatric
- Not established in children.
- Renal adjustment
- No adjustment needed for mild-moderate impairment. Severe (CrCl <20): max 10mg/day.
- Hepatic adjustment
- No adjustment for mild-moderate. Severe: use caution.
- Geriatric
- Start 2.5mg daily; slower titration; monitor for bradycardia and hypotension.
- Max dose
- 20mg/day (hypertension); 10mg/day (HFrEF)
Pharmacokinetics
Onset
1-2 hours
Peak effect
Tmax 2-4 hours; antihypertensive effect over 1-2 weeks
Duration
24 hours (QD dosing)
Half-life
~10-12 hours
Bioavailability
~88% (first-pass metabolism ~10-15%)
Protein binding
~30%
Metabolism
Hepatic via CYP3A4 (~50%) and CYP2D6 (~50%); metabolites inactive
Excretion
~50% renal (unchanged + metabolites); ~50% fecal
Contraindications
- Severe bradycardia (<60 bpm)
- Second or third-degree AV block
- Sick sinus syndrome
- Cardiogenic shock
- Severe asthma or COPD (relative—less risk than non-selective beta-blockers)
- Severe peripheral arterial disease
- Hypersensitivity to bisoprolol
Side effects
Common
FatigueBradycardiaHypotensionDizzinessHeadacheCold extremitiesGastrointestinal upsetSleep disturbances
Serious
- Severe bradycardia / heart block
- Heart failure decompensation
- Bronchospasm (less common than non-selective BBs)
- Masking of hypoglycemia
- Peripheral vascular insufficiency
- Depression
- Sexual dysfunction
Pregnancy & lactation
Pregnancy
Crosses placenta; may cause fetal bradycardia, hypoglycemia, and growth restriction. Use lowest effective dose. Monitor newborn for 48-72h after delivery (bradycardia, hypoglycemia).
Lactation
Excreted in breast milk in low concentrations (~3% of maternal dose); infant exposure minimal. Generally considered compatible with breastfeeding. Monitor infant for bradycardia.
Drug interactions
Adrenaline
Severe
Textbook
Marked rise in BP.
Adrenaline should not be given to patients receiving β blockers.
Source: KDT 7e · p133
Amiloride
Severe
Textbook
Hyperkalaemia more likely.
Source: KDT 7e
Sofosbuvir
Severe
Textbook
Severe bradycardia.
Extreme caution advised if amiodarone is co-administered with sofosbuvir and a beta blocker.
Source: Harrison 22e · unknown
Aminophylline
Severe
Database
Drug interaction classified as: antagonism
Source: DDInter
Atazanavir
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Ceritinib
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Clonidine
Severe
Database
Beta-blocker masks clonidine withdrawal rebound hypertension; abrupt discontinuation of either can cause hypertensive crisis.
Withdraw bisoprolol first over 1-2 weeks, then taper clonidine.
Source: Kimi deep-research + Cla
Diltiazem
Severe
Database
Increased propensity for AV block, severe bradycardia, and decreased left ventricular function.
Avoid concurrent administration. The concurrent administration of diltiazem with a beta blocker is contraindicated.
Source: DDInter
Disopyramide
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Dolasetron
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Dyphylline
Severe
Database
Drug interaction classified as: antagonism
Source: DDInter
Related guidelines
Ask House about Bisoprolol
Continue into a citation-backed clinical answer with the drug context already attached.
Sources: KD Tripathi 7e, Goodman & Gilman 14e, BNF·Verified: 2026-05-19 · House clinical team·Cockpit curated: 2026-05-19