bisoprolol.pdf

8/10/2019 bisoprolol.pdf

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Bisoprolol

Cardioselective Beta-Blocker

Status: February 2001


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2 Bisoprolol

Merck KGaADarmstadt, Germany

www.bisoprolol.com


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4 Bisoprolol

5.1.1 Haemodynamics5.1.2 Electrophysiology5.1.3 1-selectivity5.1.4 Receptor occupancy5.1.5 Lung function5.1.6 Peripheral circulation5.1.7 Metabolism5.1.8 2-receptor density5.1.9 Plasma renin activity5.1.10 Fibrinolytic system5.1.11 Dose-response relationship

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25

25

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292932333335384148485051

4.2 Distribution

4.3 Metabolism and excretion

4.4 Elimination half-life

4.5 Interactions

4.6 Variability of plasma concentrations

5 Clinical profile

5.1 Clinical pharmacology

4 Pharmacokinetics

4.1 Bioavailability


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6 Bisoprolol

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78

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80

80

82

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84

84868990

91

91

9595

7.1 Duration of action7.2 Haemodynamics

7.3 Success rate

7.4 Silent ischaemia

7.5 Cardioprotection

7 Treatment of angina pectoris incoronary heart disease

7.6 Therapeutic comparison incoronary patients

8 Treatment of chronic heart failure

8.1 CIBIS

6.8 Safety and efficacy in special populations6.8.1 Elderly hypertensives6.8.2 Diabetic hypertensives

7.6.1 Bisoprolol and atenolol7.6.2 Bisoprolol and nifedipine7.6.3 Bisoprolol and verapamil7.6.4 Bisoprolol and isosorbide dinitrate

8.1.1 Heart rate variability8.1.2 Pharmacoeconomic analyses


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8 Bisoprolol

Absorption rate: >90%

First-pass effect:


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10 Bisoprolol

Thus, bisoprolol is less lipophilic than propranolol but more lipophilicthan atenolol [3]. This middle position is the determinant factor forthe virtually ideal pharmacokinetic profile of bisoprolol.

Tab. 1: Partition coefficients of bisoprolol at 37C [113,190].

pH Partition log (PC)coefficient (PC) metabolisation

n-Octanol/ 7.4 4.8 0.68phosphate buffer

n-Octanol/Davies 7.0 1.09 0.04

universal buffer 7.4 2.5 0.40


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12 Bisoprolol

BetaxololAtenolol Bisoprolol

1.8 : 1

Propranolol

1 : 35 1 : 35

1 : 75

300 : 1

ICI 118.551

no selectivity

increasing1-selectivity

increasing2-selectivity

Fig.2: Ratio of constants of inhibition (ci)

ci / 1-receptors: ci / 2-receptors determined in ligand-binding studies,as a measure of the affinity of various -blockers to 1-and 2-receptors,respectively [according to 186,187].


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22 Bi l l


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22 Bisoprolol

Fig. 4: Mean plasma concentrations of bisoprolol following repeated oraladministration of 10 mg bisoprolol once daily healthy volunteers,patients with cirrhosis of the liver and patients with cirrhosis of theliver and ascites [103].

0 h48 72 96 168

Healthy volunteers (n = 8, t1/2=10.0h)Patients with cirrhosis of the liver (n = 8, t1/2 =11.8h)Patients with cirrhosis of the liver and ascites (n = 5, t1/2 =15.3h)

14412024

40

100

plasma concentration (ng/ml)

80

60

20

0192

In the human organism, half of a bisoprolol dose is transformedinto three metabolites (M1, M2, M3 in Fig.5), none of which have a

-blocking effect. The weakly active metabolite M4 could not bedetected in the human organism and presumably occurs only intraces as a metabolic intermediate stage [45,113].

An accumulation factor of 1.2 was observed with a single dailydose of bisoprolol for one week [113]. Together with the maximumfirst-pass effect of 10%, this means that with a single daily dosethe first-pass effect and accumulation counteract each other.Therefore, during maintenance therapy the bodys stock of the drugis at exactly the same level as the administered dose in each doseinterval. This applies to all the therapeutic dose levels on accountof the linearity of the kinetics.

24 Bisoprolol


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24 Bisoprolol

Fig.6: Degree of metabolisation with 1-selective -blockers. Balancedclearance and no active metabolites with bisoprolol [according to 45,113],small proportions of active metabolites with betaxolol and metoprolol.

0 BetaxololAtenolol Bisoprolol

100

metabolisation of various -blockers (%)

50

0Metoprolol

Balanced clearance

50 % unchanged50 % metabolised

Excretionapprox. 95% renal

2 % faecal

Unchanged substanceMetabolites

26 Bisoprolol


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26 Bisoprolol

Cimetidine, a potent liver enzyme inhibitor, does not influence theelimination half-life of bisoprolol [102]. Therefore, no interactionsbetween drugs inhibiting liver enzymes and bisoprolol need to beexpected. The pharmacokinetic properties of theophylline were notaffected by simultaneous therapy with bisoprolol [184]. Concurrenttreatment with bisoprolol and the anticoagulant warfarin had noadditional influence on the prothrombin time [184].

Simultaneous administration of bisoprolol and procainamide inpatients with ventricular tachyarrhythmia led to a therapeuticallydesirable prolongation of the ventricular refractory period. Treat-ment of ventricular arrhythmia with a combination of bisoprololand procainamide proved to be well tolerated in this study [175].

28 Bisoprolol


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28 Bisoprolol

4.6 Variability of plasma concentrationThe pharmacokinetics of bisoprolol are stable.

Bisoprolol exhibits a low inter- and intra-individual variability ofplasma levels on account of its high bioavailability and theminimum sensitivity of its kinetics to disturbing factors, as alsoshown in a study in 8 coronary patients [113, 114]. The plasmaconcentrations measured 2 hours after administration of

10mg or 20mg bisoprolol were 49.0 5.07 ng/ml (x SD)and 100.9 11.3 ng /ml (x SD). The inter-individual scatter ofplasma concentrations was remarkably low (coefficient ofvariation 10.3% and 11.2%). As to be expected on the basis ofits linearity of kinetics, a doubling of the dose also led to adoubling of plasma concentrations [114]. Moreover, evenabove the therapeutic dosage range the kinetics of bisoprololare independent of the dose [113]. These characteristics

find expression in the therapeutic reliability of bisoprolol in theindications angina pectoris and essential hypertension.

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5 Clinical profile

-blockers are established drugs for the treatment of essentialhypertension and angina pectoris.

A beneficial effect in the prophylaxis of recurrent infarction hasbeen proved for -blockers.

Bisoprolol, a highly 1-selective -blocker, has a reliable24-hour action in hypertension and angina pectoris when admin-istered once daily. The success rates for both indications are

about 80%.Recently, it has been established that some -blockers reducemortality and morbidity in patients with congestive heart failure(CHF).

In ambulatory patients with New York Heart AssociationClass III and IV CHF, bisoprolol reduced total mortality by 34%and sudden death by 44%.

5.1 Clinical pharmacology

5.1.1 Haemodynamics

-blockers generally have a heart-rate reducing effect anda negatively inotropic effect. With regard to patients with latentcardiac insufficiency, the negatively inotropic active component

should be small so as to prevent as far as possible the cardiacinsufficiency from becoming manifest.

In haemodynamic studies bisoprolol showed only a small nega-tively inotropic effect.

The influence of 5 and 20 mg bisoprolol on the haemodynamics incoronary patients was investigated 2 hours after oral administration,using flow-directed catheters in the right ventricle and radionuclideventriculography [164]. After only 5mg bisoprolol, there wasa distinct decrease in heart rate, rate-pressure product and cardiacindex both at rest and also during exercise. These haemodynamic

Bisoprolol30


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changes are oxygensparing mechanisms and desirable for thecoronary patient. The increase in peripheral arterial resistance fol-lowing acute administration of-blockers without ISA is known andmust be regarded as a reflex phenomenon. The effects following20 mg bisoprolol were quantitatively only slightly different fromthose following 5 mg (Fig.8) [164].

Neither of the two dosages of bisoprolol tested had a significanteffect on the ejection fraction (EF) or pulmonary capillarypressure (PCP) either at rest or during ergometric exercise (Fig.9).

Fig. 8: Mean relative changes in heart rate (HR), rate-pressure product (RPP),cardiac index (CI) and total peripheral resistance (TPR) at rest (R)and during identical exercise (Ex). Measurements were carried outbefore and 2 hours after oral administration of 5mg (n = 6) and 20 mgbisoprolol (n=10) to coronary patients (conditions at rest before

-blockade= 100%) [according to 164].

RR Ex Ex R Ex R Ex

200

(%)

100

0

180

160

140

120

80

60

40

20

RPPHR Cl TPR

Pretreatment value 20mg5 mg


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Fig.11: Course of the airway resistance (AWR) and heart rate (HR) before (b)and after single oral administration of placebo, 20 mg bisoprolol and100mg atenolol to 12 coronary patients suffering concomitantly fromchronic obstructive bronchitis (x; SEM; n =12, cross-over design) [63].

90

50

7

AWR (cm H2O/l/s)

70

HR (beats/min)

8

9

b

Placebo

2 4 8 24 b 2 4 8 24 b 2 4 8 24 h

AtenololBisoprolol

No clinically relevant deterioration of the lung function wasobserved.In the presence of COLD,however, in particular seasonalfluctuations in lung function became evident [64].

In a randomised 4-fold cross-over single-dose study in 12 hyper-tensive patients suffering concomitantly from bronchialasthma, there was a significant increase in the airway resistancewith 100mg atenolol as compared with placebo, whereasafter 10 and 20mg bisoprolol no changes were measured as

compared with placebo (Fig.12). As opposed to 100mg atenolol,1-selectivity was maintained at 10 and 20mg bisoprolol.

The effects on the cardiovascular parameters were, however,comparable with both 1-blockers [49].


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Bisoprolol40


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Fig.14: Isoprenaline-(I-)induced decrease in the diastolic blood pressure (DBP)before and 30 minutes after i.v. administration of placebo and various

-blockers to healthy volunteers (x, n =16)[107].

DBP (mm Hg)

30 min after administrationof placebo or the -blocker

64

60

0.25

20

40

1 4 16 g I 64

60

0.25

20

40

1 4 16 g I

Before administrationof placebo or the -blocker

64

60

0.25

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40

1 4 16 g I 64

60

0.25

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1 4 16 g I

64

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1 4 16 g I 64

60

0.25

20

40

1 4 16 g I

DBP (mm Hg)

Bisoprolol(0.07 mg/kg)

Placebo(saline)

Metoprolol(0.2 mg/kg)

Acebutolol(0.8 mg/kg)

Propranolol(0.2 mg/kg)

Penbutolol(0.04 mg/kg)

80

80

80 80

80

80


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Bisoprolol44


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Fig.16: Serum concentrations of glucose and lactate for 2 hours after 0.1 I.U.insulin/kg body weight i.v., 3 hours after the oral administration of3 different -blockers and placebo [112].

1.5

min.60

1.7

5

3

0.71200

1.1

4

0

glucose (mmol/l )

30 45 90

1.3

0.9

lactate (mmol/l )

min.60 1200 30 45 90

2

1

Bisoprolol 10 mgMetoprolol 50 mg

Propranolol 40 mgControl

monitoring is necessary during therapy with bisoprolol andno adjustment is usually necessary in the dosage of oral anti-diabetic preparations.

In an acute study, healthy volunteers received insulin 3 hours afterthe oral administration of various-blockers. The metabolicreactions with 10mg bisoprolol did not differ from those withplacebo, in particular the duration of the hypoglycaemic phase wasnot prolonged and there was no change in the course of serumlactate concentration as compared with the control [112].This mustbe considered as a consequence of the high1-selectivity ofbisoprolol (Fig.16).


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Bisoprolol52


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Systematic treatment of essential hypertension reduces cardio-vascular morbidity and mortality [10]. Essential hypertensionis not usually associated with pronounced clinical symptoms.Therefore, patients do not always take their medication ona regular basis. Single daily administration and a treatment withfew side-effects favour patient compliance.With one daily dose bisoprolol has a reliable 24-hour effecton the blood pressure at rest and during exercise.The 24-hour

effect is ascribable in particular to the favourableelimination half-life.

As a single daily dose, bisoprolol normalised the blood pressurefor 24 hours.

In two randomised double-blind studies it could be shown that in adosage range of 5-20 mg once daily bisoprolol reduces the bloodpressure almost in proportion to the dose in patients with essentialhypertension (initial diastolic blood pressure 95-120mm Hg)[104,185,186]. In the first study the reduction in blood pressureand heart rate in comparison to the initial status was determined24 hours after the last single oral dose of 8 weeks of treatment[185,186]. A comparable dose-proportional reduction in theseparameters, measured approx. 24 hours after the last dose of biso-prolol in each case, was achieved in a second study (15 patientsper dose group) during 12 weeks of treatment with bisoprolol(Fig.19) [104].

Further studies confirmed the dose-dependent efficacy of 5 to20 mg bisoprolol in patients with mild to moderate hypertension[32,55].

In the course of a 7-day placebo phase after withdrawal ofbisoprolol there was a slow re-increase in blood pressure andheart rate [104].

6 Treatment of essential hypertension

6.1 Blood pressure at rest duration of action

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The effective lowering of the blood pressure over 24 hours aftera single dose of bisoprolol was confirmed in a further study [100].In 8 patients with mild to moderate hypertension, continuousambulatory 24-hour measurements of blood pressure were carriedout during treatment with 10mg bisoprolol. The circadian rhythmwas maintained while the blood pressure was effectively low-ered for 24 hours; the blood pressure values were lowered morestrongly during the active day phase than in the resting phase at

night (Fig.20). Similar results were achieved with 5mg bisoprololafter a treatment period of 2 weeks [134].

Fig.20: Hourly mean values of systolic blood pressure (SBP) and diastolicblood pressure (DBP) on the last day under placebo and after4 weeks of treatment with 10 mg bisoprolol [100].

h5 9 11 2119131

100

180160

140

80

60

233 7 15 17

120SBP

DBP

mm Hg

last day under placeboafter 4 weeks with 10mg bisoprolol


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Bisoprolol58


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When used as monotherapy for essential hypertension, biso-prolol resulted in successful treatment for over 80% of thepatients (normalisation of the diastolic blood pressure: reductionto 90mm Hg or below, even 24 hours after administration) [13].The almost full 24-hour effect was guaranteed with a singledose per day even under conditions of stress.

In an open prospective multicentre study [91] the antihypertensiveeffect of monotherapy with bisoprolol was investigated in 2,012patients.Aim of the treatment was to lower the sitting diastolicblood pressure to values below 95mm Hg or by at least 10mm Hg.The patients were first treated with 5 mg bisoprolol for 4 weeks,and if blood pressure lowering was inadequate at this dose,with 10mg bisoprolol for a further 4 weeks. Out of the 1,067 fullyevaluable cases, 75.9% reached the therapeutic goal under 5mgbisoprolol.

Increase of the dose to 10 mg bisoprolol in the nonrespondersresulted in a cumulative responder rate of 93.7%. The therapyresult was independent of the age of the patients treated(Figs.24,25).

In the double-blind dose finding study already mentioned [186]the responder rate was 60%. 24 hours after drug adminis-tration (defined as lowering of the diastolic blood pressure tovalues 90mm Hg) and 80% (= lowering of the diastolic bloodpressure 95mm Hg).

6.3 Normalisation rate

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Fig.23: Mean values (SEM) for the systolic (SBP) and diastolic blood pressure (DBP),and heart rate (HR) at rest (A), at maximum ergometric exercise (B) andin the 5th recovery minute (C), according to dose groups with individualiseddoses before and after 6 weeks of treatment with bisoprolol [148].

SBP(mm Hg)

160

140

220

200

180

DBP(mm Hg)

100

80

120

HR(beats/min)

60

80

120

100

A restB max. exerciseC 5 min recovery

before start 6 wk

A B C

A B C

n = 4 5n = 4 1

5 mg

A B C

10mg

A B C

n = 7 1n = 7 0

A B C

A B C

20mg

n = 2 2n = 2 2

A B C

A B C

n = 4 0n = 3 7

non-responders

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Fig.25: Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heartrate (HR) prior to and during 8 weeks of therapy with bisoprolol(xSD). Presented are values of patients who received 5 mg bisoprololfrom week 0 to 4 and 10mg bisoprolol from week 4 to 8 (n = 332)as well as of patients who were given 5 mg bisoprolol throughout theentire study period (n = 835). For 34 patients no dosage data areavailable from week 4 on [91].

weeks4

100

180

140

6080

80

160

120

mm Hg andbeats/min.

DBP

SBP

HR

5 mg bisoprolol from week 0 to 4 and10 mg bisoprolol from week 4 to 8 (n =332) 5 mg bisoprolol from week 0 to 8 (n = 835)


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despite a similar reduction in heart rate for both agents bisoprololproduced significantly greater reductions in average 24-hour systolicand diastolic blood pressure than showed atenolol (p < 0.005)and a longer duration of action [138].

A further study carried out in the same design as the BIMS [116]confirmed the stronger antihypertensive effect observed undertreatment with bisoprolol.

In another international multicentre double-blind study 249 hyper-tensives received 5mg bisoprolol,10 mg bisoprolol or 50mgatenolol, respectively, as a single daily dose [121]. In all treatmentgroups there was a statistically significant reduction in bloodpressure and heart rate, measured 24 hours after the last adminis-tration. The reduction in blood pressure was most pronouncedunder 10 mg bisoprolol, the difference to atenolol being greaterthan to 5mg bisoprolol. The responder rate (diastolic bloodpressure 90 mm Hg) as well as the reduction in blood pressurewere comparable in the 5 mg bisoprolol group and atenolol group,corresponding to a dose ratio of 1:10 for bisoprolol:atenolol.

This dose ratio of bisoprolol and atenolol was also confirmed infurther studies [110].


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7 Treatment of angina pectoris inh t di


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coronary heart disease

The objective of anti-anginal therapy is to reduce the number of angina pectoris attacks to a minimum, and to increase thepatients exercise tolerance. This objective is achieved by therapywith bisoprolol.

Unlike the reduction in blood pressure, the anti-anginal effect of-blockers is more closely correlated to the plasma concentration

or to the bodys stock of the drug.

Bisoprolol still exhibits a full anti-anginal effect 24 hours afteradministration. The long duration of action is a result of thelong plasma elimination half-life and does not have to be for-cibly achieved by relative overdose in single administration,a special pharmaceutical formulation or repeated daily adminis-tration, as is the case with other anti-anginal drugs [30, 182].

The anti-ischaemic and anti-anginal effect of bisoprolol was inve-stigated in numerous controlled, randomised, double-blind studiesfollowing single oral doses or with periods of treatment lastingup to 8 weeks [60,65,117,124,147,161,164,183].

As little as 5mg bisoprolol was effective and with 10mg almostmaximal effects were achieved. With regard to the reduction inischaemic ST segment depression in the exercise ECG and the

increase in exercise tolerance of coronary patients, these studiesshowed no difference between 10 mg and 20 mg bisoprolol [117,161,181]. Bisoprolol increases the exercise tolerance in patientswith varying degrees of impaired coronary reserve.

In randomised, double-blind, controlled studies in patients withstable angina pectoris the 24-hour effect of bisoprolol in a dosagerange of 5-20 mg was demonstrated [60,145,147,181].

7.1 Duration of action


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bisoprolol was adapted from the pilot studies [119, 171] and thedosage regimen for atenolol corresponded to that used in theISIS I-study. The tolerability was similar for both substances and theadverse effects reported were rare and mainly well known for

-blockers or due to the natural course of the disease. The reduc-tion of heart rate and blood pressure was similar in both groups,leading to a reduction of the myocardial oxygen consumption witha positive influence on myocardial ischaemia. A cardioprotectiveeffect after MI can therefore be postulated for bisoprolol [119].

In single daily administration bisoprolol proved to be equallyeffective as other anti-anginal agents, some of which requirerepeated daily administration.

7.6.1 Bisoprolol and atenololIn the randomised, double-blind, cross-over study already referredto on p. 80,19 coronary patients were treated for 6 weeks ineach case with single daily doses of 5 mg bisoprolol,10 mg biso-prolol or 100mg atenolol [126]. There was no significant differencebetween the 3 therapies with regard to duration of exercise, time upto the occurrence of an ST segment depression of 0.1 mV, frequencyof attacks and nitroglycerin consumption. Only the rate-pressure

product at maximum exercise was reduced to a lesser extent under5 mg bisoprolol than under10mg bisoprolol and 100 mg atenolol,the doses which are to be described as equivalent [126].

In 40 coronary patients, who received 5 mg bisoprolol (see above)or 50mg atenolol for 6 months (cross-over study), there wasa comparable improvement in exercise tolerance and ST segmentdepression under both therapies (Fig.31) [182].

In an international double-blind randomised study (MIRSA),157patients with stable angina pectoris were treated with bisoprolol

7.6 Therapeutic comparison in coronary patients

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7.6.2 Bisoprolol and nifedipine

The total ischaemic burden which includes both symptomatic andasymptomatic ischaemic episodes as well as the number andduration of ischaemic episodes were investigated in a large double-blind multicentre study (TIBBS = Total Ischaemic Burden BisoprololStudy) which compared bisoprolol with nifedipine slow release (s.r.)[176]. 330 patients with stable angina pectoris, positive exercise testand at least two transient ischaemic episodes during a 48-hour

Holter monitoring were included in the study. During the first4 weeks (phase 1) bisoprolol was administered at a daily dose of10mg and nifedipine s.r. at 20mg b.i.d.; for a further 4 weeks(phase 2) the dosages were doubled to bisoprolol 20 mg once dailyand nifedipine s.r. 40 mg b.i.d. A 48-hour Holter monitoring wasperformed at the end of each treatment phase.

Fig.32: Effects of bisoprolol and nifedipine slow release (s.r.) on total

ischaemic burden. Reduction compared to baseline is significant withboth drugs and the difference in reduction between bisoprolol andnifedipine is also significant (p < 0.01), the reduction being greaterunder bisoprolol [176].

20mgBaseline

10mg

250

minxmm/48h

0

200

150

100

50

2x40mgBaseline

2x20mgBisoprolol Nifedipine s.r.


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in the whole population, there were, however, fewer deaths inthe bisoprolol group (53 patients or 16.6%) compared to placebo,where 67 patients (20.9%) died (Fig.35).

Furthermore subgroup analyses demonstrated additional benefitsfor certain patient groups:

a 47% reduction in mortality (p < 0.01) in patients withouthistory of MI (Fig.36)

a 53% reduction in mortality in patients with dilated cardio-myopathy (Fig.37)

a 42% reduction in mortality (p = 0.05) in patients with aventricular rate > 80 bpm.

Fig.35: Survival curves in CIBIS patients (n = 641). Within two years67 patients (20.9%) died in the placebo group and 53 (16.6%) in thebisoprolol group (p = 0.22 log rank test) [50].

0

survival (%)

survival time (days)

200 400 600 800 1000 1200 140040

60

80

100

BisoprololPlacebo


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The primary objective of CIBIS II was to evaluate the effect of biso-prolol1.25-10mg daily (both given in addition to standard therapy)on long-term all-cause mortality, in comparison to placebo.Secondary endpoints included cardiovascular mortality (pump failure,sudden death, fatal MI, other cardiovascular deaths, unknowncause of death), hospital admissions, combined endpoints (cardio-vascular mortality or hospitalisation for cardiovascular reasons)and permanent treatment withdrawal.

The study was stopped early, after the second interim analysisshowed a significant mortality benefit in favour of bisoprolol. Meanfollow-up was 1.3 years.

8.2.1 Primary endpoint (all-cause mortality)

Bisoprolol showed a highly significant beneficial effect on theprimary endpoint all-cause mortality irrespective of aetiology or

severity of the disease.156 patients (11.8%) of patients died in thebisoprolol group, compared with 228 (17.3%) in the placebogroup (p < 0.0001).The estimated annual mortality was 8.8% forbisoprolol and 13.2% for placebo.Thus, bisoprolol reduced mortalityby 34%; the hazard ratio was 0.66 (95% CI 0.54- 0.81) (Fig.38).

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Placebo Bisoprolol Hazard ratio p(n =1,320) (n =1,327) (95 % CI)

All-cause hospital 513 440 0.80 0.0006admission (39%) (33%) (0.71- 0.91)

All cardiovascular 161 119 0.71 0.0049deaths (12%) (9%) (0.56 - 0.90)

Combined 463 388 0.79 0.0004endpoint (35%) (29%) (0.69 - 0.90)

Permanent 192 194 1.00 0.98treatment (15%) (15%) (0.82 -1.22)withdrawals

8.2.3 Additional analyses

Additional analyses demonstrated that the greatest effect ofbisoprolol on mortality was in the reduction of sudden death; therewas a 42% lower rate of sudden death among patients onbisoprolol (4% vs 6%, p = 0.011) (Tab.7). There were also fewerdeaths from pump failure in the bisoprolol group, though thiswas not statistically significant (3% vs 4%, p = 0.17). However, manydeaths had to be classified for the purposes of the trial as beingof unknown cause (i.e. they were unwitnessed or insufficiently docu-mented). Significantly fewer deaths of unknown cause were recor-ded in the bisoprolol group (2% vs 4%, p = 0.0012), which suggeststhat many of these deaths were in fact from cardiac causes.

There were no significant differences between the groups in thenumber of deaths from other cardiovascular causes, or non-cardiovascular causes. There were significantly fewer admissionsfor worsening heart failure among bisoprolol-treated patients(12% vs 18%, p = 0.0001).

Tab.6: CIBIS II secondary endpoints [51].


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Bisoprolol102


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bisoprolol 10mg, and 33% on placebo. The tolerability of studymedication was rated as very good by 81- 82% of patients receivingbisoprolol and by 84% of patients receiving placebo.

A double-blind cross-over study [190] compared the prophylacticefficacy of bisoprolol, 5 mg/day, with that of metoprolol, 50mg,twice daily, in patients who had suffered from migraine with or with-out aura for at least two years. Patients were required to havesuffered at least 3 migraine attacks during a four-week run in-phase.

Treatment with each agent lasted 12 weeks. In 78 patients forwhom efficacy data could be compared, both-blockers reducedthe mean frequency of migraine by about 50%, compared withthe run in-phase. No differences in tolerability were observedbetween the two drugs.

Patients undergoing major vascular surgery are at risk for seriousperioperative cardiac complications such as MI and cardiacdeath. Bisoprolol reduces the incidence of death from cardiaccauses and non-fatal MI in high- risk patients undergoingmajor vascular surgery.

The Dutch Echocardiographic Cardiac Risk Evaluation ApplyingStress Echocardiography (DECREASE) study [142] was carried outin 112 patients undergoing major vascular surgery who hadone or more cardiac risk factors, but who were not already takinga -blocker or did not have extensive wall motion abnormalities(demonstrated by dobutamine echocardiography either at rest orduring stress testing). Patients were randomised to bisoprolol(started at least one week before surgery and continued for 30 dayspostoperatively) or standard care.The starting dose of bisoprololwas 5mg /day, increased to 10 mg/day if the heart rate remainedabove 60 beats per minute.

9.3 Perioperative risk reduction


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Principal symptom Number of %patients

Bradycardia 8 0.59

Giddiness 3 0.22

Gastrointestinal disorders 4 0.29

Malaise 3 0.22

Dyspnoea 2 0.15

Asthmatic bronchites 1 0.07

Nightmares 1 0.07

Feelings of anxiety 1 0.07

Hot flushes 1 0.07

Tab.8: Drop-outs due to undesirable side-effects from a total patientpopulation of n=1,396 [31].

Fig. 40: Rating of therapy with bisoprolol by doctor (a) and patient (b) [91].

good

moderatepoorno data

good

moderatepoorno data

a b

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Tab.9: Adverse events from post marketing surveillance studies in15,290 patients [41].

Adverse reactions Number Incidenceof reports (% )

Nervous system

Tiredness 214 1.4

Dizziness 141 0.9

Headache 169 1.1

Sleep disturbances 143 0.9

Vivid dreams 2

Psychic disturbances (e.g. depressive mood) 31 0.2

Eyes

Visual disturbances 2

Conjunctivitis 6

Reduced lacrimation 1

Cardiovascular system

Paraesthesias 322 2.1

Bradycardia 69 0.5

Orthostatic hypotension 15 0.1

Intensification of Raynauds phenomenon 4

Airways

Dyspnoea in patients predisposed to 139 0.9bronchospasm (e.g. in asthmatic bronchitis)

Gastrointestinal tract

Gastrointestinal complaints ( e.g. diarrhoea, 187 1.2constipation, nausea, abdominal pain)

Musculosceletal system

Muscle weakness 8

Skin

Skin reactions (e.g. i tching/pruritus, f lush, 39 0.3sweating, skin rash)

Urogenital organs

Potency disorders 110 0.7

109m

12 References


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12.1 General1 Australia/ New Zealand Heart Failure Research

Collaborative Group.Randomized, placebo-controlled trialof carvedilol in patients with congestive heart failure dueto ischemic heart disease. Lancet 1997;349: 375.

2 Cruickshank JM.Beta-blockers continue to surprise us.Eur Heart J 2000;21: 354.

3 Cruickshank JM.The clinical importance of cardioselectivityand lipophilicity in beta-blockers. Am Heart J 1980;100: 160.

4 Doughty RN et al.Effects of beta-blocker therapy onmortality in patients with heart failure: a systematic overviewof randomized trials. Eur Heart J 1997;18: 560 .

5 Fagerberg B et al.Effect of metoprolol CR/XL in chronicheart failure: Metoprolol CR/XL Randomized Intervention Trialin Heart Failure (MERIT-HF). Lancet 1999;353: 2001.

6 Gottlieb SS et al.Effect of beta-blockade on mortalityamong high-risk and low-risk patients after myocardialinfarction. N Engl J Med 1998;339: 489.

7 Haffner SM et al.Mortality from coronary heart disease insubjects with type2 diabetes and in nondiabetic subjectswith and without prior myocardial infarction. N Engl J Med1998; 339: 229.

8 Heidenreich PA et al.Effect of beta-blockade on mortalityin patients with heart failure: A meta-analysis of randomizedclinical trials. J Am Coll Cardiol 1997;30: 27.

9 Holmer SR et al. -adrenergic blockers lower renin inpatients treated with ACE-inhibitors and diuretics. Heart1998; 80: 45.


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184 Warrington SJ et al.Bisoprolol: Studies on potential inter-

actions with theophylline and warfarin in healthy volunteers.J Cardiovasc Pharmacol 1990;16 (Suppl 5): 164.

185 Weiner L et al.Antihypertensive effects of bisoprololduring once daily administration in patients with essentialhypertension. A dose-ranging study with parallel groups.Eur J Clin Pharmacol 1986;29: 517.

186 Weiner L et al.Dose-effect relationship and longterm

effects of bisoprolol in mild to moderate hypertension.J Cardiovasc Pharmacol 1986;8 (Suppl 11): 106.

187 Wellstein A et al.Affinity and selectivity of-adrenoceptorantagonists in vitro. J Cardiovasc Pharmacol 1986;8 (Suppl 11): 36.

188 Wellstein A et al.Concentration kinetics of propranolol,bisoprolol and atenolol in humans assessed with

chemical detection and a subtype selective adrenoceptor.J Cardiovasc Pharmacol 1986;8 (Suppl 11): 41.

189 Wellstein A et al.Reduction of exercise tachycardia in manafter propranolol, atenolol and bisoprolol in comparison tobeta-adrenoceptor occupancy. Eur Heart J 1987;8 (Suppl M): 3.

190 Wrz R et al.Migraine prophylaxis with bisoprolol. (HeadacheQuarterly, Current Treatment and Research 1992;3: 64-72).Translated from R. Wrz et al. Migrneprophylaxe durchBisoprolol. Fortschr. Med 1992;110: 268-272.

191 Wotschokowsky M.Pharmakologisch relevante physiko-chemische Eigenschaften von Bisoprolol-hemifumarat(EMD 33 512). Merck KGaA, Darmstadt,1985.

192 ZHU LM et al.The efficacy of once-daily bisoprolol,lacidipine and lisinopril on the 24-hour blood pressure inpatients with essential hypertension. J Hypertension 1997;15 (Suppl 4): 212

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Bisoprolol


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Bisoprolol at a glance

m W 811195070201

Bisoprolol is reliably effective for 24 hours in hypertensionand coronary artery disease (angina pectoris) with a singledose per day.

Bisoprolol has demonstrated significant survival benefit in

CHF patients whatever the aetiology of the disease. Bisoprolol is well tolerated in all three indications.

Bisoprolol has a high 1-selectivity over the entire thera-peutic dosage range and at all times.

Bisoprolol is the most potent1-selective -blocker thusrequiring the lowest substance intake.

Bisoprolol is in general metabolically neutral (lipids/ long-term therapy, glucose).

Bisoprolol has a bioavailability of about 90%.

Bisoprolol is removed from the plasma via 2 equallyeffective routes of clearance (balanced clearance):

50% metabolisation to inactive metabolite50% renal excretion of the unchanged substance.

No dosage adjustment of bisoprolol is necessary in patientswith mild to moderate renal or hepatic dysfunction.A maximum dose of 10 mg/day is called for only in terminalstages of insufficiency.

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