Bisoprolol

Use caution with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to repeated challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects. Disease-related concerns:

In general, patients with bronchospastic disease should not receive beta-blockers; for patients with bronchospastic disease who do not respond to or cannot tolerate other therapies, initial low doses of beta1-selective bisoprolol may be employed and used cautiously with close monitoring. Ensure patient has an inhaled beta2-agonist immediately available. At doses ≥20 mg/day, slight asymptomatic increases in airway resistance and decreases in forced expiratory volume (FEV1) has been observed.

Consider preexisting conditions such as sick sinus syndrome before initiating.

Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.

Use with caution in patients with compensated heart failure and monitor for a worsening of the condition. Patients should be stabilized on heart failure regimen prior to initiation of beta-blocker. Beta-blocker therapy should be initiated at very low doses with gradual and very careful titration. Adjustment of other medications (ACE inhibitors and/or diuretics) may be required

Use with caution in patients with hepatic impairment; dosage adjustment required with severe impairment.

Use with caution in patients with myasthenia gravis.

Can precipitate or aggravate symptoms of arterial insufficiency in patients with PVD and Raynaud's disease. Use with caution and monitor for progression of arterial obstruction.

Adequate alpha-blockade is required prior to use of any beta-blocker.

Beta-blockers without alpha1-adrenergic receptor blocking activity should be avoided in patients with Prinzmetal variant angina since unopposed alpha1-adrenergic receptors mediate coronary vasoconstriction and can worsen anginal symptoms (Mayer, 1998).

Beta-blocker use has been associated with induction or exacerbation of psoriasis, but cause and effect have not been firmly established.

Use with caution in patients with a history of psychiatric illness; may cause or exacerbate CNS depression.

Use with caution in patients with renal impairment; dosage adjustment required with Clcr • Thyroid disease: May mask signs of hyperthyroidism (eg, tachycardia). If hyperthyroidism is suspected, carefully manage and monitor; abrupt withdrawal may precipitate thyroid storm. Concurrent drug therapy issues:

Use with caution in patients on concurrent verapamil or diltiazem; bradycardia or heart block can occur.

Use with caution in patients receiving digoxin; bradycardia or heart block can occur.

Use with caution in patients receiving inhaled anesthetic agents known to depress myocardial contractility. Special populations:

Bradycardia may be observed more frequently in elderly patients (>65 years of age); dosage reductions may be necessary. Other warnings/precautions:

Beta-blocker therapy should not be withdrawn abruptly (particularly in patients with CAD), but gradually tapered to avoid acute tachycardia, hypertension, and/or ischemia. Severe exacerbation of angina, ventricular arrhythmias, and myocardial infarction (MI) have been reported following abrupt withdrawal of beta-blocker therapy. Temporary but prompt resumption of beta-blocker therapy may be indicated with worsening of angina or acute coronary insufficiency.

Chronic beta-blocker therapy should not be routinely withdrawn prior to major surgery.