Bisoprolol: NHS information and prescribing guide

Bisoprolol is a cardioselective beta-blocker that is widely prescribed across the NHS.

It is available as bisoprolol fumarate in tablet form and is used for several cardiovascular conditions.

Licensed indications include:

• Chronic heart failure: bisoprolol is one of the first-line beta-blockers recommended by NICE (NG106) for stable heart failure with reduced ejection fraction
• Hypertension (high blood pressure): used when other first-line treatments are not suitable, or as add-on therapy
• Angina: to reduce the frequency and severity of chest pain episodes

Bisoprolol is also sometimes prescribed off-label for conditions such as fast heart rhythms (tachyarrhythmias), migraine prevention and anxiety-related palpitations.

The medicine works by blocking beta-1 adrenergic receptors in the heart, which reduces heart rate, lowers blood pressure and decreases the oxygen demand of the heart muscle.

Because it is cardioselective, it has less effect on the lungs than non-selective beta-blockers, though caution is still needed in patients with respiratory conditions.

Bisoprolol tablets should be swallowed whole with a glass of water.

They can be taken with or without food, though taking them at the same time each day helps maintain a steady level of the medicine in your body.

Key prescribing points:

• Usual starting dose for hypertension or angina: 5 mg to 10 mg once daily
• Heart failure starting dose: 1.25 mg once daily, increased gradually at intervals of at least 2 weeks
• Maximum dose: 10 mg once daily for most indications
• Timing: most prescribers recommend a morning dose to reduce daytime drowsiness

For heart failure, the BNF recommends a careful titration schedule: 1.25 mg for 1 to 2 weeks, then 2.5 mg, then 3.75 mg, then 5 mg, then 7.

5 mg, and finally 10 mg, with each step lasting at least 2 weeks. Your doctor will monitor your heart rate, blood pressure and symptoms at each stage.

If you miss a dose, take it as soon as you remember unless it is nearly time for your next dose. Never take a double dose to make up for a missed one.

For more detailed information, see our bisoprolol dosage guide.

Like all medicines, bisoprolol can cause side effects, although not everybody gets them. The most common ones are well documented in the BNF and the NHS medicines information.

Very common (more than 1 in 10 people):

• Tiredness, particularly during the first weeks of treatment

Common (up to 1 in 10 people):

• Dizziness and light-headedness
• Cold hands and feet
• Headache
• Nausea or vomiting
• Diarrhoea or constipation

Uncommon (up to 1 in 100 people):

• Sleep disturbances and vivid dreams
• Low mood or depression
• Slow heartbeat (bradycardia)
• Muscle cramps
• Breathing difficulties in susceptible individuals

For a detailed discussion of how to manage these effects, see our dedicated page on bisoprolol side effects.

The NHS advises that most side effects are mild and improve with time. You should not stop taking bisoprolol without speaking to your doctor first.

Bisoprolol can interact with a number of other medicines. Always tell your doctor or pharmacist about everything you are taking, including over-the-counter medicines and herbal supplements.

Important interactions include:

• Verapamil and diltiazem (calcium channel blockers): can cause dangerously slow heart rates and should generally not be used with bisoprolol
• Clonidine: stopping clonidine while on bisoprolol can cause a dangerous surge in blood pressure; clonidine should be withdrawn gradually and only after bisoprolol has been stopped
• Other blood-pressure-lowering medicines: the combined effect may lead to excessively low blood pressure
• Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen and similar medicines can reduce the blood-pressure-lowering effect of bisoprolol
• Insulin and oral diabetes medicines: bisoprolol can mask the warning signs of low blood sugar (hypoglycaemia), particularly tremor and fast heartbeat
• Digoxin: combined use can increase the risk of a slow heart rate

The BNF contains a comprehensive list of interactions. Your pharmacist can check for interactions whenever you start a new medicine.

Bisoprolol is not suitable for everyone. The following groups should either avoid it or use it only under close medical supervision.

Bisoprolol should not be taken if you have:

• Uncontrolled heart failure requiring hospital treatment
• Very slow heart rate (below 50 bpm) before starting treatment
• Very low blood pressure (systolic below 90 mmHg)
• Severe asthma or severe COPD
• Untreated phaeochromocytoma
• Metabolic acidosis
• Sick sinus syndrome or second- or third-degree heart block (unless a pacemaker is fitted)

Use with caution if you have:

• Mild to moderate asthma or COPD (NICE advises that cardioselective beta-blockers can be used with care)
• Diabetes (bisoprolol may mask hypoglycaemia symptoms)
• Peripheral vascular disease (Raynaud's phenomenon may worsen)
• Psoriasis (beta-blockers may trigger or worsen flares)
• A history of depression

Pregnancy and breastfeeding: bisoprolol should only be used during pregnancy if the potential benefit outweighs the risk. It is not recommended during breastfeeding.

Discuss alternatives with your doctor.

Bisoprolol is available as a generic medicine and is one of the most commonly prescribed beta-blockers on the NHS.

It is listed in the BNF and is included on local formularies across England, Scotland, Wales and Northern Ireland.

Key points about NHS prescribing:

• Available in strengths of 1.25 mg, 2.5 mg, 3.75 mg, 5 mg, 7.5 mg and 10 mg tablets
• The generic form is very affordable, typically costing the NHS a few pence per tablet
• It is available on standard NHS prescription (currently subject to the standard prescription charge in England)
• Patients in Scotland, Wales and Northern Ireland receive free prescriptions
• Patients with certain long-term conditions may be eligible for a medical exemption certificate

Bisoprolol is on the NHS England national medicines optimisation dashboard as one of the recommended beta-blockers for heart failure.

NICE guidance (NG106) specifically names bisoprolol alongside carvedilol and nebivolol as first-choice options.

If you have questions about your prescription, your community pharmacist is always available to help.