Bisoprolol/hctz 2.5mg/6.25mg Tabs
It is used to treat high blood pressure.
Drug Class
Antihypertensive
Pharmacologic Class
Beta-adrenergic Blocker (Cardioselective) / Thiazide Diuretic
Pregnancy Category
Category D
FDA Approved
Aug 1993
DEA Schedule
Not Controlled
Overview
What is this medicine?
This medication is a combination of two drugs: a beta-blocker (bisoprolol) and a diuretic (hydrochlorothiazide). It works by relaxing blood vessels and removing excess fluid from your body, which helps to lower your blood pressure and reduce the strain on your heart.
How to Use This Medicine
Taking Your Medication Correctly
To get the most benefit from your medication, take it exactly as directed by your doctor. Carefully read all the information provided with your prescription, and follow the instructions closely. Continue taking your medication as prescribed by your doctor or healthcare provider, even if you start feeling well.
It's essential to establish a routine when taking this medication. Try to take it at the same time every day to help you remember. Since this medication may increase urine production, it's best to avoid taking it too close to bedtime to minimize sleep disruptions.
If you're taking cholestyramine or colestipol, consult with your pharmacist to determine the best way to take these medications in combination with your prescribed drug. Additionally, if you're on a low-salt or salt-free diet, discuss this with your doctor to ensure safe and effective treatment.
Storing and Disposing of Your Medication
To maintain the quality and safety of your medication, store it at room temperature in a dry place, avoiding bathrooms and areas with high humidity. Keep all medications in a secure location, out of reach of children and pets.
When disposing of unused or expired medications, do not flush them down the toilet or pour them down the drain unless instructed to do so. Instead, consult with your pharmacist for guidance on the proper disposal method. You may also want to explore local drug take-back programs for a safe and environmentally friendly way to dispose of your medications.
What to Do If You Miss a Dose
If you miss a dose, take it as soon as you remember. However, if it's close to the time for your next scheduled dose, skip the missed dose and resume your regular dosing schedule. Avoid taking two doses at the same time or taking extra doses, as this can increase the risk of adverse effects.
To get the most benefit from your medication, take it exactly as directed by your doctor. Carefully read all the information provided with your prescription, and follow the instructions closely. Continue taking your medication as prescribed by your doctor or healthcare provider, even if you start feeling well.
It's essential to establish a routine when taking this medication. Try to take it at the same time every day to help you remember. Since this medication may increase urine production, it's best to avoid taking it too close to bedtime to minimize sleep disruptions.
If you're taking cholestyramine or colestipol, consult with your pharmacist to determine the best way to take these medications in combination with your prescribed drug. Additionally, if you're on a low-salt or salt-free diet, discuss this with your doctor to ensure safe and effective treatment.
Storing and Disposing of Your Medication
To maintain the quality and safety of your medication, store it at room temperature in a dry place, avoiding bathrooms and areas with high humidity. Keep all medications in a secure location, out of reach of children and pets.
When disposing of unused or expired medications, do not flush them down the toilet or pour them down the drain unless instructed to do so. Instead, consult with your pharmacist for guidance on the proper disposal method. You may also want to explore local drug take-back programs for a safe and environmentally friendly way to dispose of your medications.
What to Do If You Miss a Dose
If you miss a dose, take it as soon as you remember. However, if it's close to the time for your next scheduled dose, skip the missed dose and resume your regular dosing schedule. Avoid taking two doses at the same time or taking extra doses, as this can increase the risk of adverse effects.
Lifestyle & Tips
- Take this medication exactly as prescribed, usually once daily in the morning.
- Do not stop taking this medication suddenly, as it can worsen your condition. Your doctor will guide you on how to safely reduce the dose if needed.
- Continue to follow a low-sodium diet as recommended by your doctor or dietitian.
- Engage in regular physical activity as advised by your healthcare provider.
- Limit alcohol intake, as it can further lower blood pressure and cause dizziness.
- Monitor your blood pressure and heart rate regularly at home if advised by your doctor.
- Stay hydrated, but avoid excessive fluid intake unless directed by your doctor, especially if you experience symptoms of low sodium.
Available Forms & Alternatives
Dosing & Administration
Adult Dosing
Standard Dose:
2.5 mg bisoprolol / 6.25 mg HCTZ orally once daily
Dose Range:
2.5 - 10 mg
Condition-Specific Dosing:
hypertension:
Initial dose is 2.5 mg bisoprolol / 6.25 mg HCTZ once daily. May be titrated up to a maximum of 10 mg bisoprolol / 25 mg HCTZ once daily, usually by doubling the dose at 14-day intervals.
Pediatric Dosing
Neonatal:
Not established
Infant:
Not established
Child:
Not established
Adolescent:
Not established
Dose Adjustments
Renal Impairment:
Mild:
No specific adjustment needed for CrCl > 30 mL/min.
Moderate:
Use with caution. For bisoprolol, maximum dose of 10 mg/day is recommended if CrCl < 20 mL/min. Hydrochlorothiazide becomes less effective with CrCl < 30 mL/min.
Severe:
Contraindicated if anuric. Not recommended if CrCl < 30 mL/min due to hydrochlorothiazide component.
Dialysis:
Not recommended. Bisoprolol is not significantly dialyzable. Hydrochlorothiazide is not effective in severe renal impairment.
Hepatic Impairment:
Mild:
No specific adjustment.
Moderate:
Use with caution. Bisoprolol clearance may be reduced. Hydrochlorothiazide can precipitate hepatic coma in severe impairment.
Severe:
Use with extreme caution; dosage adjustment for bisoprolol may be necessary. Hydrochlorothiazide is generally not recommended.
Pharmacology
Mechanism of Action
Bisoprolol is a beta-1 selective (cardioselective) adrenergic receptor blocking agent. It decreases heart rate, myocardial contractility, and renin release from the kidney, leading to reduced cardiac output and blood pressure. Hydrochlorothiazide is a thiazide diuretic that inhibits the reabsorption of sodium and chloride ions in the distal convoluted tubule, leading to increased excretion of sodium, chloride, and water, and to a lesser extent, potassium and magnesium. This reduces plasma volume and peripheral vascular resistance.
Pharmacokinetics
Absorption:
Bioavailability:
Bisoprolol: ~90%; Hydrochlorothiazide: 65-75%
Tmax:
Bisoprolol: 2-4 hours; Hydrochlorothiazide: 1-2.5 hours
FoodEffect:
Bisoprolol: Not significantly affected by food; Hydrochlorothiazide: Food may increase absorption slightly but not clinically significant.
Distribution:
Vd:
Bisoprolol: 2-3 L/kg; Hydrochlorothiazide: 0.8-1.7 L/kg
ProteinBinding:
Bisoprolol: ~30%; Hydrochlorothiazide: 40-68%
CnssPenetration:
Bisoprolol: Limited; Hydrochlorothiazide: Limited
Elimination:
HalfLife:
Bisoprolol: 9-12 hours; Hydrochlorothiazide: 5.6-14.8 hours
Clearance:
Bisoprolol: ~15 L/h; Hydrochlorothiazide: Renal clearance is primary
ExcretionRoute:
Bisoprolol: Renal (50% unchanged, 50% metabolites); Hydrochlorothiazide: Renal (primarily unchanged)
Unchanged:
Bisoprolol: ~50%; Hydrochlorothiazide: >95%
Pharmacodynamics
OnsetOfAction:
Bisoprolol: 1-2 hours; Hydrochlorothiazide: ~2 hours
PeakEffect:
Bisoprolol: 2-4 hours; Hydrochlorothiazide: 4-6 hours
DurationOfAction:
Bisoprolol: 24 hours; Hydrochlorothiazide: 6-12 hours
Safety & Warnings
BLACK BOX WARNING
Abrupt cessation of therapy with beta-blocking agents should be avoided, especially in patients with ischemic heart disease. If possible, the dosage should be gradually reduced over a period of about 1 to 2 weeks. If angina worsens or acute coronary insufficiency develops, bisoprolol/HCTZ administration should be reinstituted promptly, at least temporarily, and other measures appropriate for the management of angina pectoris should be taken. Because coronary artery disease is common and may be unrecognized, it may be prudent not to discontinue bisoprolol/HCTZ therapy abruptly even in patients treated only for hypertension.
Side Effects
Serious Side Effects: Seek Medical Attention Immediately
Although rare, some people may experience severe and potentially life-threatening side effects while taking this medication. If you notice any of the following symptoms, contact your doctor or seek medical help right away:
Signs of an allergic reaction, such as:
+ Rash
+ Hives
+ Itching
+ Red, swollen, blistered, or peeling skin with or without fever
+ Wheezing
+ Tightness in the chest or throat
+ Trouble breathing, swallowing, or talking
+ Unusual hoarseness
+ Swelling of the mouth, face, lips, tongue, or throat
Signs of fluid and electrolyte problems, including:
+ Mood changes
+ Confusion
+ Muscle pain or weakness
+ Fast or abnormal heartbeat
+ Severe dizziness or passing out
+ Increased thirst
+ Seizures
+ Feeling very tired or weak
+ Decreased appetite
+ Unable to pass urine or changes in urine production
+ Dry mouth
+ Dry eyes
+ Severe upset stomach or vomiting
Signs of pancreatitis (pancreas problems), such as:
+ Severe stomach pain
+ Severe back pain
+ Severe upset stomach or vomiting
Signs of kidney problems, including:
+ Unable to pass urine
+ Changes in urine production
+ Blood in the urine
+ Sudden weight gain
New or worsening chest pain
Slow heartbeat
Shortness of breath
Sudden weight gain or swelling in the arms or legs
Dark urine or yellow skin and eyes
Abnormal burning, numbness, or tingling sensations
Eye Problems
This medication can cause certain eye problems, which may lead to permanent vision loss if left untreated. If you experience any eye problems, symptoms such as changes in vision or eye pain usually occur within hours to weeks of starting the medication. Contact your doctor immediately if you notice any of these signs.
Lupus
If you have lupus, this medication may cause your condition to become active or worsen. Inform your doctor right away if you experience any new or worsening symptoms.
Skin Cancer
Rarely, people taking hydrochlorothiazide have developed certain types of skin cancer. Protect your skin from the sun and follow your doctor's instructions for skin checks. Contact your doctor immediately if you notice any changes in the color or size of a mole, or any new or changing skin lumps or growths.
Other Side Effects
Like all medications, this drug can cause side effects. Many people experience no side effects or only mild ones. However, if you are bothered by any of the following side effects or if they persist, contact your doctor or seek medical help:
Dizziness
Fatigue
Weakness
Headache
This is not an exhaustive list of possible side effects. If you have questions or concerns about side effects, contact your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Although rare, some people may experience severe and potentially life-threatening side effects while taking this medication. If you notice any of the following symptoms, contact your doctor or seek medical help right away:
Signs of an allergic reaction, such as:
+ Rash
+ Hives
+ Itching
+ Red, swollen, blistered, or peeling skin with or without fever
+ Wheezing
+ Tightness in the chest or throat
+ Trouble breathing, swallowing, or talking
+ Unusual hoarseness
+ Swelling of the mouth, face, lips, tongue, or throat
Signs of fluid and electrolyte problems, including:
+ Mood changes
+ Confusion
+ Muscle pain or weakness
+ Fast or abnormal heartbeat
+ Severe dizziness or passing out
+ Increased thirst
+ Seizures
+ Feeling very tired or weak
+ Decreased appetite
+ Unable to pass urine or changes in urine production
+ Dry mouth
+ Dry eyes
+ Severe upset stomach or vomiting
Signs of pancreatitis (pancreas problems), such as:
+ Severe stomach pain
+ Severe back pain
+ Severe upset stomach or vomiting
Signs of kidney problems, including:
+ Unable to pass urine
+ Changes in urine production
+ Blood in the urine
+ Sudden weight gain
New or worsening chest pain
Slow heartbeat
Shortness of breath
Sudden weight gain or swelling in the arms or legs
Dark urine or yellow skin and eyes
Abnormal burning, numbness, or tingling sensations
Eye Problems
This medication can cause certain eye problems, which may lead to permanent vision loss if left untreated. If you experience any eye problems, symptoms such as changes in vision or eye pain usually occur within hours to weeks of starting the medication. Contact your doctor immediately if you notice any of these signs.
Lupus
If you have lupus, this medication may cause your condition to become active or worsen. Inform your doctor right away if you experience any new or worsening symptoms.
Skin Cancer
Rarely, people taking hydrochlorothiazide have developed certain types of skin cancer. Protect your skin from the sun and follow your doctor's instructions for skin checks. Contact your doctor immediately if you notice any changes in the color or size of a mole, or any new or changing skin lumps or growths.
Other Side Effects
Like all medications, this drug can cause side effects. Many people experience no side effects or only mild ones. However, if you are bothered by any of the following side effects or if they persist, contact your doctor or seek medical help:
Dizziness
Fatigue
Weakness
Headache
This is not an exhaustive list of possible side effects. If you have questions or concerns about side effects, contact your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Seek Immediate Medical Attention If You Experience:
- Severe dizziness or fainting (especially when standing up)
- Very slow heart rate (less than 50 beats per minute)
- Shortness of breath, swelling in your ankles or feet, or unusual weight gain (signs of worsening heart failure)
- Unusual tiredness or weakness
- Muscle cramps or spasms
- Numbness or tingling in your hands or feet
- Persistent nausea, vomiting, or diarrhea
- Signs of gout (sudden, severe joint pain, redness, swelling)
- Yellowing of the skin or eyes (jaundice)
Before Using This Medicine
Before Taking This Medication: Important Information to Share with Your Doctor
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the symptoms you experienced.
A known sulfa allergy.
Certain health conditions, including:
+ Respiratory problems like asthma or chronic obstructive pulmonary disease (COPD).
+ Heart conditions, such as heart block, heart failure (weak heart), shock caused by heart problems, or a slow heartbeat.
+ Inability to urinate.
Current medications, including:
+ Lithium.
+ Dofetilide.
+ Any other medications similar to this one. If you are unsure, consult your doctor or pharmacist.
* All your prescription and over-the-counter (OTC) medications, natural products, and vitamins. This is not an exhaustive list, and it is crucial to discuss all your medications and health issues with your doctor.
Remember, it is vital to verify that it is safe to take this medication with all your existing medications and health conditions. Never start, stop, or adjust the dosage of any medication without first consulting your doctor.
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the symptoms you experienced.
A known sulfa allergy.
Certain health conditions, including:
+ Respiratory problems like asthma or chronic obstructive pulmonary disease (COPD).
+ Heart conditions, such as heart block, heart failure (weak heart), shock caused by heart problems, or a slow heartbeat.
+ Inability to urinate.
Current medications, including:
+ Lithium.
+ Dofetilide.
+ Any other medications similar to this one. If you are unsure, consult your doctor or pharmacist.
* All your prescription and over-the-counter (OTC) medications, natural products, and vitamins. This is not an exhaustive list, and it is crucial to discuss all your medications and health issues with your doctor.
Remember, it is vital to verify that it is safe to take this medication with all your existing medications and health conditions. Never start, stop, or adjust the dosage of any medication without first consulting your doctor.
Precautions & Cautions
Important Warnings and Cautions
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
Caution with Daily Activities
Until you know how this medication affects you, avoid driving and other tasks that require alertness. To minimize the risk of dizziness or fainting, get up slowly from a sitting or lying position, and be cautious when climbing stairs.
Monitoring Your Condition
Follow your doctor's instructions for checking your blood pressure and heart rate. Also, have your blood work and other laboratory tests done as directed by your doctor. Be aware that this medication may interfere with certain lab tests, so inform all your healthcare providers and lab personnel that you are taking this medication.
Interactions with Other Substances
Before consuming alcohol, marijuana, or other forms of cannabis, or taking prescription or over-the-counter (OTC) medications that may cause drowsiness, discuss the potential risks with your doctor.
Low Blood Sugar Risk
This medication may mask symptoms of low blood sugar, such as a rapid heartbeat, which can increase the risk of severe or prolonged low blood sugar. This is particularly concerning for people with diabetes, children, and those who are fasting, undergoing surgery, or experiencing nausea and vomiting. If you have questions or concerns, consult your doctor. If you have diabetes, closely monitor your blood sugar levels.
Stopping the Medication
Do not stop taking this medication abruptly, as this can lead to worsening chest pain or even a heart attack, especially if you have certain types of heart disease. To avoid side effects, your doctor will instruct you on how to gradually stop taking this medication. If you experience new or worsening chest pain or other heart problems, seek medical attention immediately.
Additional Precautions
Be aware of the risk of gout attacks and take precautions in hot weather or during physical activity by drinking plenty of fluids to prevent dehydration. Before taking OTC products that may increase blood pressure, such as cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, or certain natural products, consult your doctor. If you experience excessive sweating, fluid loss, vomiting, or diarrhea, which can lead to low blood pressure, inform your doctor.
Sun Sensitivity
This medication may increase your risk of sunburn. Take necessary precautions when exposed to the sun, and inform your doctor if you experience unusual sun sensitivity.
Thyroid Conditions
This medication may mask symptoms of an overactive thyroid, such as a rapid heartbeat. If you have an overactive thyroid and stop taking this medication abruptly, your condition may worsen and become life-threatening. Discuss your condition with your doctor.
Allergic Reactions
If you have a history of severe allergic reactions, inform your doctor. You may be at risk of a more severe reaction if you are exposed to the allergen again. If you use epinephrine to treat severe allergic reactions, consult your doctor, as this medication may reduce the effectiveness of epinephrine.
Pregnancy and Breastfeeding
If you are pregnant, plan to become pregnant, or are breastfeeding, discuss the benefits and risks of this medication with your doctor.
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
Caution with Daily Activities
Until you know how this medication affects you, avoid driving and other tasks that require alertness. To minimize the risk of dizziness or fainting, get up slowly from a sitting or lying position, and be cautious when climbing stairs.
Monitoring Your Condition
Follow your doctor's instructions for checking your blood pressure and heart rate. Also, have your blood work and other laboratory tests done as directed by your doctor. Be aware that this medication may interfere with certain lab tests, so inform all your healthcare providers and lab personnel that you are taking this medication.
Interactions with Other Substances
Before consuming alcohol, marijuana, or other forms of cannabis, or taking prescription or over-the-counter (OTC) medications that may cause drowsiness, discuss the potential risks with your doctor.
Low Blood Sugar Risk
This medication may mask symptoms of low blood sugar, such as a rapid heartbeat, which can increase the risk of severe or prolonged low blood sugar. This is particularly concerning for people with diabetes, children, and those who are fasting, undergoing surgery, or experiencing nausea and vomiting. If you have questions or concerns, consult your doctor. If you have diabetes, closely monitor your blood sugar levels.
Stopping the Medication
Do not stop taking this medication abruptly, as this can lead to worsening chest pain or even a heart attack, especially if you have certain types of heart disease. To avoid side effects, your doctor will instruct you on how to gradually stop taking this medication. If you experience new or worsening chest pain or other heart problems, seek medical attention immediately.
Additional Precautions
Be aware of the risk of gout attacks and take precautions in hot weather or during physical activity by drinking plenty of fluids to prevent dehydration. Before taking OTC products that may increase blood pressure, such as cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, or certain natural products, consult your doctor. If you experience excessive sweating, fluid loss, vomiting, or diarrhea, which can lead to low blood pressure, inform your doctor.
Sun Sensitivity
This medication may increase your risk of sunburn. Take necessary precautions when exposed to the sun, and inform your doctor if you experience unusual sun sensitivity.
Thyroid Conditions
This medication may mask symptoms of an overactive thyroid, such as a rapid heartbeat. If you have an overactive thyroid and stop taking this medication abruptly, your condition may worsen and become life-threatening. Discuss your condition with your doctor.
Allergic Reactions
If you have a history of severe allergic reactions, inform your doctor. You may be at risk of a more severe reaction if you are exposed to the allergen again. If you use epinephrine to treat severe allergic reactions, consult your doctor, as this medication may reduce the effectiveness of epinephrine.
Pregnancy and Breastfeeding
If you are pregnant, plan to become pregnant, or are breastfeeding, discuss the benefits and risks of this medication with your doctor.
Overdose Information
Overdose Symptoms:
- Severe bradycardia (very slow heart rate)
- Profound hypotension (very low blood pressure)
- Bronchospasm (difficulty breathing, wheezing)
- Acute heart failure
- Dehydration
- Severe electrolyte imbalances (e.g., hypokalemia, hyponatremia)
- Dizziness, weakness, confusion
What to Do:
Seek immediate medical attention or call 911. For poison control, call 1-800-222-1222.
Drug Interactions
Contraindicated Interactions
- Anuria (due to HCTZ)
- Cardiogenic shock (due to Bisoprolol)
- Overt cardiac failure (due to Bisoprolol)
- Second or third degree AV block (without a pacemaker, due to Bisoprolol)
- Severe sinus bradycardia (due to Bisoprolol)
Major Interactions
- Lithium (HCTZ decreases renal clearance, increasing lithium toxicity)
- NSAIDs (may reduce antihypertensive and diuretic effects of HCTZ)
- Other antihypertensives (additive hypotensive effects)
- Class I antiarrhythmics (e.g., disopyramide, quinidine - additive cardiac depression with bisoprolol)
- CYP3A4 inhibitors (e.g., ketoconazole, ritonavir - may increase bisoprolol levels)
- CYP3A4 inducers (e.g., rifampin - may decrease bisoprolol levels)
- Barbiturates, narcotics, alcohol (additive orthostatic hypotension with HCTZ)
- Corticosteroids, ACTH (intensified electrolyte depletion, particularly hypokalemia with HCTZ)
- Digitalis glycosides (HCTZ-induced hypokalemia or hypomagnesemia can potentiate digitalis toxicity)
Moderate Interactions
- Antidiabetic agents (HCTZ may increase blood glucose; bisoprolol may mask hypoglycemia symptoms)
- Cholestyramine, colestipol (may impair HCTZ absorption)
- Skeletal muscle relaxants, non-depolarizing (HCTZ may potentiate effect)
- Allopurinol (increased risk of hypersensitivity reactions with HCTZ)
- Calcium salts (increased serum calcium due to decreased excretion by HCTZ)
- Pressor amines (e.g., norepinephrine - bisoprolol may blunt effect)
- Clonidine (risk of rebound hypertension if clonidine is withdrawn while on bisoprolol)
Minor Interactions
- Alcohol (may enhance orthostatic hypotension)
Monitoring
Baseline Monitoring
Blood Pressure (BP) and Heart Rate (HR)
Rationale: To establish baseline and assess efficacy and safety.
Timing: Prior to initiation
Serum Electrolytes (Potassium, Sodium, Magnesium, Calcium)
Rationale: Hydrochlorothiazide can cause electrolyte imbalances (hypokalemia, hyponatremia, hypomagnesemia, hypercalcemia).
Timing: Prior to initiation
Renal Function (BUN, Serum Creatinine, eGFR)
Rationale: To assess kidney function, which influences drug clearance and HCTZ efficacy.
Timing: Prior to initiation
Liver Function Tests (LFTs)
Rationale: To assess hepatic function, especially important for bisoprolol metabolism and HCTZ caution in severe impairment.
Timing: Prior to initiation
Blood Glucose
Rationale: HCTZ can increase blood glucose; bisoprolol can mask hypoglycemia symptoms.
Timing: Prior to initiation
Serum Uric Acid
Rationale: HCTZ can increase uric acid levels, potentially precipitating gout.
Timing: Prior to initiation
Routine Monitoring
Blood Pressure (BP) and Heart Rate (HR)
Frequency: Regularly, e.g., weekly during titration, then monthly/quarterly once stable
Target: BP: <130/80 mmHg (individualized); HR: 50-90 bpm
Action Threshold: Symptomatic hypotension, bradycardia (<50 bpm), or uncontrolled hypertension
Serum Electrolytes (Potassium, Sodium, Magnesium)
Frequency: Within 1-2 weeks of initiation/dose change, then every 3-6 months or as clinically indicated
Target: Potassium: 3.5-5.0 mEq/L; Sodium: 135-145 mEq/L; Magnesium: 1.7-2.2 mg/dL
Action Threshold: Significant deviations from normal range, especially hypokalemia or hyponatremia
Renal Function (BUN, Serum Creatinine)
Frequency: Within 1-2 weeks of initiation/dose change, then every 3-6 months or as clinically indicated
Target: Within normal limits for age/sex
Action Threshold: Significant increase in creatinine or decrease in eGFR
Blood Glucose
Frequency: Periodically, especially in diabetic patients
Target: Individualized based on diabetes management
Action Threshold: Persistent hyperglycemia or difficulty controlling blood glucose
Symptom Monitoring
- Dizziness or lightheadedness (especially upon standing)
- Fatigue or weakness
- Shortness of breath or swelling in ankles/feet (signs of worsening heart failure)
- Muscle cramps or weakness (signs of electrolyte imbalance)
- Numbness or tingling (signs of electrolyte imbalance)
- Chest pain or palpitations (especially if stopping abruptly)
- Signs of gout (joint pain, swelling)
Special Patient Groups
Pregnancy
Category D. Use is generally not recommended during pregnancy, especially during the second and third trimesters, due to potential fetal harm (e.g., fetal growth restriction, bradycardia, neonatal jaundice, thrombocytopenia, electrolyte disturbances). Benefits may outweigh risks in life-threatening situations.
Trimester-Specific Risks:
First Trimester:
Limited data, but generally avoided due to potential for fetal harm with both components.
Second Trimester:
Increased risk of fetal growth restriction, bradycardia, and other adverse effects due to bisoprolol. Hydrochlorothiazide can cause fetal/neonatal jaundice, thrombocytopenia, and electrolyte imbalances.
Third Trimester:
Highest risk of adverse fetal and neonatal effects, including those listed for the second trimester, plus oligohydramnios and neonatal respiratory distress.
Lactation
Both bisoprolol and hydrochlorothiazide are excreted into breast milk. While levels are generally low, there is a potential for adverse effects in the infant (e.g., bradycardia, hypotension, hypokalemia). Use with caution; consider alternative agents or monitor infant closely for adverse effects. Hydrochlorothiazide may also suppress lactation.
Infant Risk:
Low to moderate risk; monitor for bradycardia, hypotension, lethargy, and electrolyte disturbances.
Pediatric Use
Safety and effectiveness have not been established in pediatric patients. Use is generally not recommended.
Geriatric Use
Elderly patients may be more sensitive to the effects of bisoprolol/HCTZ, particularly regarding blood pressure lowering and electrolyte imbalances. Renal function often declines with age, necessitating careful monitoring and potential dose adjustments. Start with lower doses and titrate slowly.
Clinical Information
Clinical Pearls
- This combination is useful for patients whose blood pressure is not adequately controlled by monotherapy or for whom initial combination therapy is appropriate.
- Advise patients to take the medication in the morning to avoid nocturia (frequent urination at night) due to the diuretic component.
- Educate patients about the importance of not abruptly discontinuing the medication due to the beta-blocker component's risk of rebound hypertension or exacerbation of angina.
- Monitor for signs of electrolyte imbalance, especially hypokalemia, which can be exacerbated by concomitant use of corticosteroids or digitalis.
- Caution in patients with asthma, COPD, or other bronchospastic diseases, as even cardioselective beta-blockers can cause bronchoconstriction at higher doses or in susceptible individuals.
- Be aware of the potential for increased blood glucose and uric acid levels due to hydrochlorothiazide, especially in patients with diabetes or gout.
Alternative Therapies
- ACE inhibitors (e.g., lisinopril)
- Angiotensin Receptor Blockers (ARBs) (e.g., valsartan)
- Calcium Channel Blockers (CCBs) (e.g., amlodipine)
- Other diuretics (e.g., loop diuretics, potassium-sparing diuretics)
- Other beta-blockers (e.g., carvedilol, metoprolol)
- Other antihypertensive classes (e.g., alpha-blockers, direct vasodilators)
Cost & Coverage
Average Cost:
$10 - $50 per 30 tablets (generic)
Generic Available:
Yes
Insurance Coverage:
Tier 1 or 2 (Generic)
General Drug Facts
If your symptoms or health issues persist or worsen, it is essential to contact your doctor promptly. To ensure your safety, never share your medication with others or take someone else's medication. Some medications may come with an additional patient information leaflet, so it's a good idea to check with your pharmacist. If you have any questions or concerns about this medication, don't hesitate to discuss them with your doctor, nurse, pharmacist, or other healthcare provider. In the event of a suspected overdose, immediately call your local poison control center or seek emergency medical attention. When seeking help, be prepared to provide detailed information about the overdose, including the medication taken, the amount, and the time it occurred.