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The following section describes when Bisoprolol must be used with special caution: Diabetes mellitus with extremely fluctuating blood glucose levels: symptoms of markedly reduced blood glucose (hypoglycemia) such as tachycardia, palpitations or sweating can be masked, strict fasting, ongoing desensitization therapy, mild disturbances of atrioventricular conduction (first degree AV block), disturbed blood flow in the coronary vessels due to vasospasms (Prinzmetal angina), peripheral arterial occlusive disease (aggravation of symptoms may occur especially when starting therapy), patients with psoriasis or with a personal history of psoriasis.
Respiratory system: In bronchial asthma or other symptomatic chronic obstructive pulmonary diseases concomitant bronchodilator therapy is indicated. An increase in airway resistance may occasionally occur in patients with asthma, requiring a higher dose of beta2 sympathomimetics.
Allergic reactions: Beta-blockers, including Bisoprolol, may increase the sensitivity to allergens and the severity of anaphylactic reactions because the adrenergic counter regulation under beta-blockade may be alleviated. Treatment with adrenaline may not always yield the expected therapeutic effect.
General anesthesia: In patients undergoing general anesthesia the anesthetist must be aware of beta-blockade. If it is thought necessary to withdraw Bisoprolol before surgery, this should be done gradually and completed about 48 hours prior to anesthesia.
Pheochromocytoma: In patients with a tumor of the adrenal gland (pheochromocytoma) Bisoprolol may only be administered after previous alpha-receptor blockade.
Thyrotoxicosis: Under treatment with Bisoprolol the symptoms of a thyroid hyperfunction (thyrotoxicosis) may be masked.
Special populations: So far no sufficient therapeutic experience is available for Bisoprolol in patients with heart failure and concomitant insulin dependent type I diabetes mellitus, severely impaired kidney function, severely impaired hepatic function, restrictive cardiomyopathy, congenital heart diseases or hemodynamically relevant organic valvular heart disease. No sufficient therapeutic experience is available either in patients with heart failure and myocardial infarction within the last 3 months.
There is insufficient experience with Bisoprolol in children, therefore the use of Bisoprolol cannot be recommended for children.
Effects on the ability to drive and use machines: It will depend on the individual patient's response to treatment especially at the start of treatment, upon change of medication, or in conjunction with alcohol.
