Metoprolol

Oral
Intravenous
Class
Adrenergic receptor blockers
Subclass
Cardioselective β-blockers
Substance name
Metoprolol tartrate
Brand names
Lopressor®
Common formulations
Tablet
See also
Metoprolol ER (Toprol XL®, Kapspargo®)
Dosage and administration
Adults patients
Treatment
Hypertension
•
Start at: 25 mg PO BID
•
Maintenance: 50-100 mg PO BID
•
Maximum: 200 mg per day
Titrate at weekly intervals based on response and tolerability. Taken with or immediately after meals.
Myocardial infarction
•
Loading: 5 mg IV q5 min for up to 3 doses
•
Subsequently: 25-50 mg PO q6-12h, then switched to twice-daily dosing over the next 2-3 days after initiation
•
Maintenance: 50-100 mg PO BID for at least 3 months and up to 1-3 years
Taken with or immediately after meals.
Stable angina
•
Start at: 50 mg PO BID
•
Maintenance: 100-400 mg PO daily
•
Maximum: 400 mg per day
Titrate at weekly intervals based on response and tolerability. Taper gradually over 1-2 weeks when discontinuing. Taken with or immediately after meals.
AF • Rate control • Off-label
•
Loading: 2.5-5 mg IV bolus over 2 minutes, for up to 3 doses
•
Subsequently: 25 mg PO BID
•
Maintenance: 200 mg PO BID
Taken with or immediately after meals.
Atrial flutter • Rate control • Off-label
•
Loading: 2.5-5 mg IV bolus over 2 minutes, for up to 3 doses
•
Subsequently: 25 mg PO BID
•
Maintenance: 200 mg PO BID
Taken with or immediately after meals.
Excessive bronchial secretions in patients with ALS • Off-label
•
25 mg PO BID
Taken with or immediately after meals.
SVT • Off-label
•
Loading: 2.5-5 mg IV q5 min, administered over 2 minutes, for up to 3 doses
•
Subsequently: 25 mg PO BID
•
Maintenance: 200 mg PO BID
•
Maximum: 400 mg per day
Taken with or immediately after meals.
Thyrotoxicosis • Off-label
•
25-50 mg PO BID-TID
Taken with or immediately after meals.
Prevention
Prevention of migraine attacks • Off-label
•
50-200 mg PO daily
Taken with or immediately after meals.
Other off-label uses
•
Treatment of hypertension in pregnancy
•
Treatment of HCM in pregnant females
•
Treatment of VT in pregnant females (idiopathic, nonsustained)
Indications for use
Labeled indications
Adults
•
Treatment of hypertension
•
Treatment of myocardial infarction
•
Treatment of stable angina
Off-label indications
Adults
•
Treatment of AF (rate control)
•
Treatment of atrial flutter (rate control)
•
Treatment of excessive bronchial secretions in patients with ALS
•
Treatment of hypertension in pregnancy
•
Treatment of HCM in pregnant females
•
Treatment of SVT
•
Treatment of thyrotoxicosis
•
Treatment of VT in pregnant females (idiopathic, nonsustained)
•
Prevention of migraine attacks
Safety risks
Boxed warnings
Exacerbation of angina pectoris, myocardial infarction
•
Do not discontinue abruptly, as coronary artery disease is common and may be unrecognized. Taper gradually over 1-2 weeks.
Contraindications
Hypersensitivity to metoprolol or its components
Non-cardiac major surgery
•
Avoid initiating high-dose β-blocker therapy in patients undergoing non-cardiac surgery because of the increased risk of bradycardia, hypotension, stroke, and death in patients with cardiovascular risk factors. Do not routinely withdraw chronic β-blocker therapy before surgery.
SBP < 100 mmHg, decompensated HF, or cardiogenic shock
Severe bradycardia, second- or third-degree AV block, or sick sinus syndrome unless a permanent pacemaker is present
Warnings and precautions
Bronchospasm
•
Use caution in patients with bronchospastic disease. Use the lowest possible dose. Consider administering concomitant β-2 agonists.
Exacerbation of arterial insufficiency
•
Use caution in patients with PAD.
Exacerbation of HF
•
Use caution when up-titrating metoprolol in patients with HF. Increase diuretics and ensure clinical stability before up-titration.
Hypertensive crisis
•
Use caution in patients with pheochromocytoma. Administer in combination with an α-blocker and only after α-blockage has been initiated.
Mask symptoms of hyperthyroidism
•
Use caution in patients with thyroid disease.
Mask symptoms of hypoglycemia
•
Use caution in patients with diabetes mellitus or patients who are fasting (surgery, not eating regularly, or vomiting).
Thyroid storm
•
Do not discontinue abruptly in patients with thyroid disease suspected of developing thyrotoxicosis.
Specific populations
Renal impairment
CrCl 0-90 mL/min
•
Use acceptable. No dose adjustment required.
Renal replacement therapy
Continuous renal replacement
•
Use acceptable. No dose adjustment required.
Intermittent hemodialysis
•
Use acceptable. No dose adjustment required.
Peritoneal dialysis
•
Use acceptable. No dose adjustment required.
Hepatic impairment
Any severity
•
Reduce starting dose. Titrate slowly.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Consider safer alternatives. Use only if clearly needed. Evidence of fetal harm in animals. Monitor neonates for hypotension, bradycardia, hypoglycemia and respiratory depression. The Hypertension Canada guidelines recommend metoprolol as one of the initial monotherapy choices for nonsevere hypertension during pregnancy.
Breastfeeding
Acceptable for use during breastfeeding.
•
Monitor infants for bradycardia and other signs of β-blockade if the mother is a slow metabolizer of metoprolol.
Undetectable levels in breastfed infants.
No overt adverse effects reported in breastfed infants.
Adverse reactions
Very common > 10%
•
Bradycardia, hypotension, dizziness
Common 1-10%
•
AV block, bronchospasm, peripheral edema, depression, diarrhea, dyspnea, fatigue, palpitations, pruritus, skin rash, wheezing
Unknown frequency
•
Agranulocytosis, arterial insufficiency, gangrene, intermittent claudication, raynaud's phenomenon, ↓ blood glucose, myocardial infarction, thyroid storm, anaphylaxis, Peyronie's disease, angina pectoris, arthralgia, ↓ libido, sexual dysfunction, depression, sleeping disorder, erectile dysfunction, hair loss, syncope
Interactions
Drug(s)
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