Combinations Not Recommended: Treatment of Stable Chronic Heart Failure: Class I Antiarrhythmic Drugs (eg, Disopyramide, Quinidine, Lidocaine, Phenytoin, Flecainide, Propafenone): Effect on atrial conduction time may be potentiated and negative inotropic effect may be increased.
Treatment of All Indications: Calcium Antagonist of the Verapamil Type and to a Lesser Extent of the Diltiazem Type: Negative influence on contractility, atrioventrivular conduction and blood pressure. IV administration of verapamil in patients on β-blocker treatment may lead to profound hypotension and atrioventricular block.
Centrally-Acting Antihypertensive Drugs eg, Clonidine and Other (eg, Methyldopa, Monoxonide, Rilmenidine): Concomitant use of centrally-acting antihypertensive drug may lead to reduction of heart rate and cardiac output to vasodilatation. Abrupt withdrawal may increase rebound hypertension.
Combinations to be Used with Caution: Treatment of Hypertension or Angina Pectoris: Class I Antiarrhythmic Drugs (eg, Disopyramide, Quinidine): Effect on atrial conduction time may be potentiated and negative inotropic effect may be increased.
Treatment of All Indications: Calcium Antagonists of the Dihydropyridine Type (eg, Felodipine and Amlodipine): Concomitant use may increase the risk of hypotension and an increase in the risk of a further deterioration of the ventricular pump function in patients with heart failure cannot be excluded.
Class III Antiarrhythmic Drugs (eg, Amiodarone): Effect on atrial conduction time may be potentiated.
Parasympathomimetic Drugs (Including Tacrine): Atrioventricular conduction time may be increased.
Other β-blockers, including eye drops, have additive effects.
Insulin and Oral Antidiabetic Drugs: Intensification of blood sugar lowering effect. Blockade of β-adrenoreceptors may mask symptoms of hypoglycaemia.
Anaesthetic Agents: Attenuation of the reflex tachycardia and increase of the risk of hypotension (see Precautions for further information on general anaesthesia).
Digitalis Glycosides: Reduction of heart rate, increase of atrioventricular conduction time.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Decreased hypotensive effect.
Beta-Sympathomimetic Agents (eg, Isoprenaline, Dobutamine): Combination with bisoprolol may reduce the effect of both agents.
Sympathomimetic that Activates both β- and α-Adrenoreceptors (eg, Noradrenaline, Adrenaline): Combination with bisoprolol may lead to blood pressure increase and exacerbated intermittent claudication. Such interactions are considered to be more likely with nonselective β-blockers.
Tricyclic Antidepressant, Barbiturates, Phenothiazines as well as Other Antihypertensive Agents: Increase blood pressure-lowering effect.
Combinations to be Considered: Mefloquine: Increased risk of bradycardia.
Monoamine Oxidase Inhibitors (except Monoamine Oxidase-B Inhibitors): Enhanced hypotensive effect of β-blockers but also risk of hypertensive crisis.
Ergotamine Derivatives: Exacerbation of peripheral circulatory disturbances.
Rifampicin: Slight reduction of the half-life of bisoprolol possibly due to the induction of hepatic drug-metabolizing enzymes. Normally, no dosage adjustment is necessary.