Conversion: Bisoprolol and Carvedilol

Availability

Dose Equivalence

General

There is little or no difference between carvedilol and bisoprolol or metoprolol in hospitalization risk. The certainty of the evidence is high.
Patients with HF with reduced ejection fraction, with no or minimal current evidence of fluid retention should be treated with one of the following three beta blockers: carvedilol, extended release metoprolol succinate, or bisoprolol
All 3 agent improved overall and event-free survival in patients with NYHA class II to III HF and probably in class IV HF

Carvedilol to Bisoprolol

Based on recommended initial starting and target doses of these 2 beta-blockers in the various clinical trials CIBIS II, US Carvedilol Studies, and COPERNICUS, and the Clinical Pharmacy Practice Guidelines for HF patients developed by Singapore Ministry of Health, we decided on a 5:1 dose conversion (eg, carvedilol 12.5 mg BD to bisoprolol 5 mg OM)
once-daily dosing for bisoprolol compared with a twice-daily dosing of carvedilol is likely to confer a higher likelihood of adherence
alpha-blockade effect is more likely to cause hypotension and/or dizziness, further discouraging adherence to carvedilol
Recommendation: Switching from carvedilol to bisoprolol may help with continuation of β-blocker treatment as well as dosage increase in HF patients with adverse symptoms or signs, allowing them to reach the target dose

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Rationale for Carvedilol

Reduces mortality in NYHA stage 2-4 has the strongest evidence for benefit in severe failure.
Greater reduction in mortality than with immediate-release metoprolol tartrate in COMET
Carvedilol might decrease mortality compared to metoprolol or bisoprolol in patients with heart failure. [The certainty of the evidence is low]
Using carvedilol is not more expensive than the alternative beta-blockers analysed in this summary. It might have a favorable cost/benefit ratio, but again, it is important to highlight this is based on low certainty evidence

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