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Metoprolol

Medically reviewed on Sep 10, 2018

Pronunciation

(me toe PROE lole)

Index Terms

  • Metoprolol Succinate
  • Metoprolol Tartrate

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule ER 24 Hour Sprinkle, Oral:

Kapspargo Sprinkle: 25 mg, 50 mg, 100 mg, 200 mg [contains corn starch]

Solution, Intravenous, as tartrate:

Lopressor: 5 mg/5 mL (5 mL [DSC])

Generic: 5 mg/5 mL (5 mL)

Solution, Intravenous, as tartrate [preservative free]:

Generic: 5 mg/5 mL (5 mL)

Solution Cartridge, Intravenous, as tartrate:

Generic: 5 mg/5 mL (5 mL)

Tablet, Oral, as tartrate:

Lopressor: 50 mg [scored]

Lopressor: 100 mg [scored; contains fd&c blue #2 aluminum lake]

Generic: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg

Tablet Extended Release 24 Hour, Oral, as succinate:

Toprol XL: 25 mg

Toprol XL: 25 mg [scored]

Toprol XL: 50 mg

Toprol XL: 50 mg [scored]

Toprol XL: 100 mg

Toprol XL: 100 mg [scored]

Toprol XL: 200 mg

Toprol XL: 200 mg [DSC] [scored]

Generic: 25 mg, 50 mg, 100 mg, 200 mg

Brand Names: U.S.

  • Kapspargo Sprinkle
  • Lopressor
  • Toprol XL

Pharmacologic Category

  • Antianginal Agent
  • Antihypertensive
  • Beta-Blocker, Beta-1 Selective

Pharmacology

Selective inhibitor of beta1-adrenergic receptors; competitively blocks beta1-receptors, with little or no effect on beta2-receptors at oral doses <100 mg (in adults); does not exhibit any membrane stabilizing or intrinsic sympathomimetic activity

Absorption

Rapid and complete

Distribution

Vd: 3.2 to 5.6 L/kg; crosses the blood brain barrier; CSF concentrations are 78% of plasma concentrations

Metabolism

Extensively hepatic via CYP2D6; significant first-pass effect (~50%)

Excretion

Urine (95%, <5% to 10% as unchanged drug; increased to 30% to 40% in poor CYP2D6 metabolizers)

Onset of Action

Oral: Immediate release tablets: Within 1 hour; Peak effect: Oral: 1 to 2 hours (Regardh 1980); IV: 20 minutes (when infused over 10 minutes)

Duration of Action

Oral: Immediate release: Variable (dose-related; 50% reduction in maximum heart rate after single doses of 20, 50, and 100 mg occurred at 3.3, 5, and 6.4 hours, respectively), Extended release: ~24 hours

Half-Life Elimination

Neonates: 5 to 10 hours (Morselli 1989); Adults: 3 to 4 hours (7 to 9 hours in poor CYP2D6 metabolizers or hepatic impairment)

Protein Binding

~10% to 12% to albumin

Special Populations: Hepatic Function Impairment

Elimination half-life may be considerably prolonged, depending on severity.

Special Populations: Race

Poor CYP2D6 metabolizers (~8% Caucasians; ~2% other populations) have several-fold higher metoprolol plasma concentrations.

Use: Labeled Indications

Angina (oral formulations): Long-term treatment of angina pectoris.

Heart failure (ER oral formulation): Treatment of stable, symptomatic (NYHA Class II or III) heart failure of ischemic, hypertensive, or cardiomyopathic origin to reduce the rate of mortality plus hospitalization in patients already receiving ACE inhibitors, diuretics, and/or digoxin.

Hypertension (oral formulations): Management of hypertension. Note: Beta-blockers are not recommended as first-line therapy (ACC/AHA [Whelton 2017]).

Myocardial infarction: Treatment of hemodynamically stable acute myocardial infarction (MI) to reduce cardiovascular mortality (injection to be used in combination with metoprolol oral maintenance therapy).

Off Label Uses

Atrial fibrillation/flutter (rate control)

Based on the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines for the Management of Patients with Atrial Fibrillation, the use of beta-blockers, including metoprolol, for ventricular rate control in patients with paroxysmal, persistent, or permanent atrial fibrillation is effective and recommended for this condition.

Atrial fibrillation prevention after cardiac surgery

Based on the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guideline for coronary artery bypass graft surgery, beta-blockers are recommended to help prevent postoperative atrial fibrillation.

Migraine prophylaxis

Data from small, randomized, active-controlled trials support the use of metoprolol for prevention of migraines [Diener 2001], [Schellenberg 2008].

Based on evidence-based guidelines for pharmacologic treatment for episodic migraine prevention in adults from the American Academy of Neurology and the American Headache Society, metoprolol is effective for migraine prevention in adults.

Supraventricular tachycardia (atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial flutter, focal atrial tachycardia, multifocal atrial tachycardia)

Based on the American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for the management of patients with supraventricular arrhythmias, the use of an oral or intravenous beta-blocker, including metoprolol, is effective and recommended for a variety of symptomatic supraventricular tachycardias (atrioventricular nodal reentrant tachycardia [AVNRT], atrioventricular reentrant tachycardia [AVRT], focal atrial tachycardia [AT], and multifocal atrial tachycardia [MAT]). In patients without pre-excitation, intravenous metoprolol is recommended for the acute treatment in hemodynamically-stable patients and oral metoprolol is recommended for the ongoing management of symptomatic supraventricular tachycardias in patients who are not candidates for, or prefer not to undergo catheter ablation. Intravenous or oral metoprolol may be useful for rate control in the acute treatment or ongoing management of hemodynamically stable patients with atrial flutter.

Thyrotoxicosis

Based on the 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis, beta-blockers, including metoprolol, are effective and recommended in the treatment of symptomatic thyrotoxicosis. Beta-blockers should also be considered in asymptomatic patients who are at increased risk of complications due to worsening hyperthyroidism [Ross 2016].

Ventricular arrhythmias

Based on the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guideline for management of patients with ventricular arrhythmias and prevention of sudden cardiac death, beta-blockers are effective for control of ventricular arrhythmias and ventricular premature beats.

Contraindications

Hypersensitivity to metoprolol, any component of the formulation, or other beta-blockers; second- or third-degree heart block

Note: Additional contraindications are formulation and/or indication specific.

Immediate-release tablets/injectable formulation:

Hypertension and angina (oral only): Sinus bradycardia; cardiogenic shock; overt heart failure; sick sinus syndrome; severe peripheral arterial circulatory disorders

Myocardial infarction (oral and injection): Severe sinus bradycardia (heart rate <45 beats/minute); significant first-degree heart block (P-R interval ≥0.24 seconds); systolic blood pressure <100 mm Hg; moderate to severe cardiac failure

Extended-release formulation: Severe bradycardia, cardiogenic shock; decompensated heart failure; sick sinus syndrome (except in patients with a functioning artificial pacemaker)

Documentation of allergenic cross-reactivity for beta-blockers is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Canadian labeling: Additional contraindications (not in US labeling): Cor pulmonale; untreated pheochromocytoma; asthma and other obstructive respiratory disease (injection only); concomitant use with anesthesia agents that cause myocardial depression

Dosing: Adult

Angina: Note: Beta-blockers are not recommended for vasospastic angina. Calcium channel blockers and nitrates are preferred in this situation (ACC/AHA [Fihn 2012]).

Immediate release (metoprolol tartrate): Oral: Initial: 50 mg twice daily; usual dosage range: 50 to 200 mg twice daily; may increase dose at weekly intervals to desired effect; maximum dose: 400 mg/day

Extended release (metoprolol succinate): Oral: Initial: 100 mg once daily; may increase dose at weekly intervals to desired effect; maximum dose: 400 mg/day

Note: Titrate dose to resting heart rate of 55 to 60 beats per minute (bpm) (ACC/AHA [Fihn 2012]). Some experts recommend titrating to a resting heart rate of 50 to 60 bpm or <50 bpm for severe angina in the absence of symptoms (eg, symptomatic bradycardia, heart block) (Kannam 2018).

Atrial fibrillation/flutter (off-label use):

Acute ventricular rate control: IV: 2.5 to 5 mg every 2 to 5 minutes (maximum total dose: 15 mg over a 10- to 15-minute period). Note: Initiate cautiously in patients with concomitant heart failure. Avoid in patients with decompensated heart failure; electrical cardioversion preferred (AHA/ACC/HRS [January 2014]; AHA [Neumar 2010]).

Maintenance of ventricular rate control:

Immediate release (metoprolol tartrate): Oral: 25 to 100 mg twice daily (AHA/ACC/HRS [January 2014])

Extended release (metoprolol succinate): Oral: 50 to 400 mg once daily (AHA/ACC/HRS [January 2014])

Atrial fibrillation prevention after cardiac surgery: Note: Initiate prior to surgery (preferentially at least 48 hours before) or postoperatively when hemodynamically stable. Continue therapy at least until the first postoperative visit in patients with no other indication for beta-blocker therapy (Lee 2018).

Immediate release (metoprolol tartrate): Oral: Initial: 25 to 50 mg twice daily; titrate to the maximally tolerated dose; maximum dose: 200 mg/day (Acikel 2008; Haghjoo 2007)

Extended release (metoprolol succinate): Oral: Initial: 50 mg once daily; titrate to the maximally tolerated dose; maximum dose: 200 mg/day (Ozaydin 2013)

Heart failure with reduced ejection fraction (HFrEF): Note: Initiate only in stable patients or hospitalized patients after volume status has been optimized and IV diuretics, vasodilators, and inotropic agents have all been successfully discontinued. Caution should be used when initiating in patients who required inotropes during their hospital course. Increase dose gradually and monitor for congestive signs and symptoms of HF making every effort to achieve target dose shown to be effective (ACCF/AHA [Yancy 2013]; MERIT-HF Study Group 1999).

Extended release (metoprolol succinate): Oral: Initial: 12.5 to 25 mg once daily; up-titrate gradually to the maximum tolerated dose; maximum dose: 200 mg/day (ACC/AHA [Yancy 2013])

Hypertension (alternative agent): Note: Not recommended in the absence of specific comorbidities (eg, ischemic heart disease, HFrEF, arrhythmia) (ACC/AHA [Whelton 2017]).

Immediate release (metoprolol tartrate): Oral: Initial: 50 mg twice daily; titrate at weekly (or longer) intervals as needed based on patient response; maximum dose: 450 mg/day; usual dosage range: 100 to 200 mg/day in 2 divided doses (ACC/AHA [Whelton 2017])

Extended release (metoprolol succinate): Oral: Initial: 25 to 100 mg once daily; titrate at weekly (or longer) intervals as needed based on patient response; maximum dose: 400 mg/day; usual dosage range: 50 to 200 mg once daily (ACC/AHA [Whelton 2017])

Migraine prophylaxis (off label use): Immediate release (metoprolol tartrate): Oral: Initial: 25 mg twice daily; titrate based on patient response up to 200 mg/day in divided doses (Bajwa 2018; Diener 2001; Schellenberg 2008)

Myocardial infarction (MI):

Early treatment: Note: Initiate an oral beta-blocker within the first 24 hours if there are no contraindications. Do not initiate metoprolol in those with signs of heart failure, a low output state, increased risk of cardiogenic shock, or other contraindications for beta-blockade (eg, second- or third-degree heart block) (ACCF/AHA [O'Gara 2013]). Beta-blockers without intrinsic sympathomimetic activity (eg, metoprolol) are preferred (Rosenson 2018).

Oral:

Immediate release (metoprolol tartrate): Initial: 25 to 50 mg every 6 to 12 hours; transition to twice daily dosing of metoprolol tartrate (immediate release) or to daily metoprolol succinate (extended release) and increase as tolerated to a maximum dose of 200 mg/day (ACCF/AHA [O'Gara 2013]).

Extended release (metoprolol succinate): Initial: 50 to 100 mg once daily is also recommended by some experts; increase as tolerated (Rosenson 2018)

IV: Note: Small doses of IV metoprolol at the time of presentation may be considered for STEMI in the case of hypertension or ongoing ischemia if no contraindications exist. Initial: 5 mg every 5 minutes as tolerated for up to 3 doses; titrate to heart rate and blood pressure; then begin oral therapy 15 to 30 minutes after the last IV dose (ACCF/AHA [O'Gara 2013]; Chen 2005; Rosenson 2018).

Secondary prevention: Note: The optimal duration of therapy is unknown, but treatment for up to 3 years is reasonable if there is no additional indication for ongoing therapy (Rosenson 2018).

Immediate release (metoprolol tartrate): Oral: 25 to 100 mg twice daily; optimize dose based on heart rate and blood pressure; continue indefinitely (Olsson 1992).

Extended release (metoprolol succinate): Oral: 100 mg once daily is also recommended by some experts (Aroesty 2018).

Supraventricular tachycardia (eg, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal atrial tachycardia) (off-label use):

Acute treatment: IV: 2.5 to 5 mg bolus over 2 minutes, may repeat with 2.5 to 5 mg bolus within a 10-minute period, up to 3 doses (ACC/AHA/HRS [Page 2016])

Maintenance therapy:

Immediate release (metoprolol tartrate): Oral: Initial: 25 mg twice daily; maximum dose: 400 mg/day (ACC/AHA/HRS [Page 2016])

Extended release (metoprolol succinate): Oral: Initial: 50 mg once daily; maximum dose: 400 mg/day (ACC/AHA/HRS [Page 2016])

Thyrotoxicosis (off-label use): Immediate release (metoprolol tartrate): Oral: 25 to 50 mg every 8 to 12 hours; may also consider administering an equivalent dose of the once-daily extended-release formulation (metoprolol succinate) (Ross 2016).

Ventricular arrhythmias (off-label use): Note: A beta-blocker is recommended for various ventricular arrhythmias including sustained or nonsustained VT, electrical storm with incessant VT, primary or secondary prevention of sudden cardiac death due to VT/VF, and ventricular premature beats. A beta-blocker is also recommended in patients with an implantable cardioverter defibrillator to reduce shocks. An antiarrhythmic drug (eg, amiodarone) may be needed in addition to beta-blockade if further arrhythmia suppression is needed (AHA/ACC/HRS [Al-Khatib 2017]).

Acute ventricular tachycardia (eg sustained VT, electrical storm with incessant VT): IV: 5 mg every 5 minutes up to 3 doses (AHA/ACC/HRS [Al-Khatib 2017])

Prevention and maintenance of ventricular arrhythmias:

Immediate release (metoprolol tartrate): Oral: Initial: 12.5 to 25 mg twice daily; increase as needed based on patient response to a maximum dose of 200 mg/day in divided doses (Kettering 2002; Kuck 2000; Seidl 1998)

Extended release (metoprolol succinate): Oral: Initial: 25 to 100 mg 1 to 2 times daily (AHA/ACC/HRS [Al-Khatib 2017])

Note: Switching dosage forms:

When switching from immediate release (metoprolol tartrate) to extended release (metoprolol succinate), the same total daily dose of metoprolol should be used. Metoprolol tartrate is typically administered in 2 to 3 divided daily doses and metoprolol succinate is administered once daily.

When switching between oral and intravenous dosage forms, in most cases, equivalent beta-blocking effect is achieved when doses in a 2.5:1 (Oral:IV) ratio is used. However, in one bioavailability study including healthy volunteers, a range of Oral:IV conversion ratios was found to be approximately 2:1 to 5:1 (Regardh 1974). Therefore, patient variability may exist and a specific ratio may not apply to all patients, especially if comorbid conditions are present. The estimated equivalent IV total daily dose should be divided into four equal doses. For example, based on a range of 2.5:1 to 5:1 ratios, if the patient is receiving a chronic oral dose of 25 mg twice daily (total daily dose of 50 mg), this would translate to 2.5 to 5 mg IV every 6 hours. Recognizing that patients receiving larger chronic oral doses should not automatically be converted to a large IV dose, consideration should be given to further reducing the initial IV dose and basing subsequent doses on the clinical response (Huckleberry 2003).

Dosing: Geriatric

Refer to adult dosing. In the management of hypertension, consider lower initial doses and titrate to response (Aronow 2011).

Dosing: Pediatric

Hypertension: Oral:

Immediate-release (metoprolol tartrate): Children ≥1 year of age and Adolescents ≤17 years of age (off-label population): Initial: 0.5 to 1 mg/kg/dose (maximum initial dose: 25 mg/dose) twice daily. Adjust dose based on patient response; maximum daily dose: 6 mg/kg/day or 200 mg/day, whichever is less (NHLBI 2011; NHBPEP 2004).

Extended-release (metoprolol succinate): Children ≥6 years of age and Adolescents: Initial: 1 mg/kg once daily (maximum initial dose: 50 mg/dose). Adjust dose based on patient response (maximum: 2 mg/kg/day or 200 mg/day, whichever is less)

Dosing: Renal Impairment

No dosage adjustment necessary.

Dosing: Hepatic Impairment

There are no specific dosage adjustments provided in the manufacturer's labeling. Consider initiating with reduced doses and gradual dosage titration due to extensive hepatic metabolism.

Extemporaneously Prepared

10 mg/mL Oral Suspension (ASHP Standard Concentration) (ASHP 2017)

A 10 mg/mL oral suspension may be made with metoprolol tartrate tablets and one of three different vehicles (cherry syrup; a 1:1 mixture of Ora-Sweet and Ora-Plus; or a 1:1 mixture of Ora-Sweet SF and Ora-Plus). Crush twelve 100 mg tablets in a mortar and reduce to a fine powder. Add 20 mL of the chosen vehicle and mix to a uniform paste; mix while adding the vehicle in incremental proportions to almost 120 mL; transfer to a calibrated bottle, rinse mortar with vehicle, and add quantity of vehicle sufficient to make 120 mL. Label "shake well" and "protect from light". Stable for 60 days.

Allen LV Jr and Erickson MA 3rd, "Stability of Labetalol Hydrochloride, Metoprolol Tartrate, Verapamil Hydrochloride, and Spironolactone With Hydrochlorothiazide in Extemporaneously Compounded Oral Liquids," Am J Health Syst Pharm, 1996, 53(19):2304-9.8893069

Administration

Oral:

Immediate release (metoprolol tartrate): Typically administered in 2 to 3 divided doses. Administer with or immediately following food (Melander 1977).

Extended release (metoprolol succinate): Administer once daily without regard to meals (Tangeman 2003; van den Berg 1990; Wikstrand 2003). May divide tablets in half; do not crush or chew.

Sprinkle capsule: May be swallowed whole or the capsule may be opened and contents sprinkled on a small amount (1 teaspoonful) of soft food (eg, applesauce, pudding, or yogurt) to be used within 60 minutes (do not store for future use).

Nasogastric tube administration: Open capsule and add contents to an all plastic oral tip syringe; add 15 mL of water. Gently shake the syringe for ~10 seconds. Immediately deliver mixture through a ≥12 French nasogastric tube. No granules should remain in the syringe; rinse syringe with additional water if necessary.

IV: When administered acutely for cardiac treatment, monitor ECG and blood pressure. Administer by IV bolus. Some centers may administer by slow infusion (ie, 5 to 10 mg of metoprolol in 50 mL of fluid) over ~30 to 60 minutes during less urgent situations (eg, substitution for oral metoprolol).

Dietary Considerations

Immediate-release tablets should be taken with or immediately following food (Melander 1977).

Storage

Injection: Store at 20°C to 25°C (68°F to 77°F). Do not freeze; protect from light.

Sprinkle capsules: Store at 20°C to 25°C (68°F to 77°F).

Tablet: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from moisture.

Drug Interactions

Abiraterone Acetate: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity. Consider therapy modification

Acetylcholinesterase Inhibitors: May enhance the bradycardic effect of Beta-Blockers. Monitor therapy

Ajmaline: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Alpha1-Blockers: Beta-Blockers may enhance the orthostatic hypotensive effect of Alpha1-Blockers. The risk associated with ophthalmic products is probably less than systemic products. Monitor therapy

Alpha2-Agonists: May enhance the AV-blocking effect of Beta-Blockers. Sinus node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound hypertensive effect of Alpha2-Agonists. This effect can occur when the Alpha2-Agonist is abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists are unavailable. Exceptions: Apraclonidine. Consider therapy modification

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Consider therapy modification

Aminoquinolines (Antimalarial): May decrease the metabolism of Beta-Blockers. Monitor therapy

Amiodarone: May enhance the bradycardic effect of Beta-Blockers. Possibly to the point of cardiac arrest. Amiodarone may increase the serum concentration of Beta-Blockers. Monitor therapy

Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Antipsychotic Agents (Phenothiazines): May enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents (Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of Beta-Blockers. Monitor therapy

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Monitor therapy

Asunaprevir: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Consider therapy modification

Barbiturates: May decrease the serum concentration of Beta-Blockers. Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Beta2-Agonists: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Monitor therapy

Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Monitor therapy

Bretylium: May enhance the bradycardic effect of Bradycardia-Causing Agents. Bretylium may also enhance atrioventricular (AV) blockade in patients receiving AV blocking agents. Monitor therapy

Brigatinib: May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Bromperidol: Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. Avoid combination

Bupivacaine: Beta-Blockers may increase the serum concentration of Bupivacaine. Monitor therapy

Calcium Channel Blockers (Nondihydropyridine): May enhance the hypotensive effect of Beta-Blockers. Bradycardia and signs of heart failure have also been reported. Calcium Channel Blockers (Nondihydropyridine) may increase the serum concentration of Beta-Blockers. Exceptions: Bepridil. Monitor therapy

Cardiac Glycosides: Beta-Blockers may enhance the bradycardic effect of Cardiac Glycosides. Monitor therapy

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Avoid combination

Cholinergic Agonists: Beta-Blockers may enhance the adverse/toxic effect of Cholinergic Agonists. Of particular concern are the potential for cardiac conduction abnormalities and bronchoconstriction. Management: Administer these agents in combination with caution, and monitor for conduction disturbances. Avoid methacholine with any beta blocker due to the potential for additive bronchoconstriction. Monitor therapy

Cobicistat: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy

CYP2D6 Inhibitors: May increase the serum concentration of Metoprolol. Management: Consider an alternative for one of the interacting drugs in order to avoid metoprolol toxicity. If the combination must be used, monitor response to metoprolol closely. Metoprolol dose reductions may be necessary. Consider therapy modification

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Dipyridamole: May enhance the bradycardic effect of Beta-Blockers. Monitor therapy

Disopyramide: May enhance the bradycardic effect of Beta-Blockers. Beta-Blockers may enhance the negative inotropic effect of Disopyramide. Monitor therapy

Dronedarone: May enhance the bradycardic effect of Beta-Blockers. Dronedarone may increase the serum concentration of Beta-Blockers. This likely applies only to those agents that are metabolized by CYP2D6. Management: Use lower initial beta-blocker doses; adequate tolerance of the combination, based on ECG findings, should be confirmed prior to any increase in beta-blocker dose. Consider therapy modification

EPINEPHrine (Nasal): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of EPINEPHrine (Nasal). Monitor therapy

EPINEPHrine (Oral Inhalation): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of EPINEPHrine (Oral Inhalation). Monitor therapy

Epinephrine (Racemic): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of Epinephrine (Racemic). Monitor therapy

EPINEPHrine (Systemic): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of EPINEPHrine (Systemic). Monitor therapy

Ergot Derivatives: Beta-Blockers may enhance the vasoconstricting effect of Ergot Derivatives. Exceptions: Nicergoline. Consider therapy modification

Fingolimod: Beta-Blockers may enhance the bradycardic effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and beta-blockers if possible. If coadministration is necessary, patients should have overnight continuous ECG monitoring conducted after the first dose of fingolimod. Monitor patients for bradycardia. Consider therapy modification

Floctafenine: May enhance the adverse/toxic effect of Beta-Blockers. Avoid combination

Grass Pollen Allergen Extract (5 Grass Extract): Beta-Blockers may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). More specifically, Beta-Blockers may inhibit the ability to effectively treat severe allergic reactions to Grass Pollen Allergen Extract (5 Grass Extract) with epinephrine. Some other effects of epinephrine may be unaffected or even enhanced (e.g., vasoconstriction) during treatment with Beta-Blockers. Consider therapy modification

Herbs (Hypertensive Properties): May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy

Imatinib: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy

Insulins: Beta-Blockers may enhance the hypoglycemic effect of Insulins. Monitor therapy

Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Monitor therapy

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Monitor therapy

Lercanidipine: May enhance the hypotensive effect of Metoprolol. Metoprolol may decrease the serum concentration of Lercanidipine. Monitor therapy

Levodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa. Monitor therapy

Lidocaine (Systemic): Beta-Blockers may increase the serum concentration of Lidocaine (Systemic). Monitor therapy

Lidocaine (Topical): Beta-Blockers may increase the serum concentration of Lidocaine (Topical). Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Lumefantrine: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy

Mepivacaine: Beta-Blockers may increase the serum concentration of Mepivacaine. Monitor therapy

Methacholine: Beta-Blockers may enhance the adverse/toxic effect of Methacholine. Avoid combination

Methoxyflurane: May enhance the hypotensive effect of Beta-Blockers. Monitor therapy

Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Midodrine: Beta-Blockers may enhance the bradycardic effect of Midodrine. Monitor therapy

Mirabegron: May diminish the antihypertensive effect of Metoprolol. Mirabegron may increase the serum concentration of Metoprolol. Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

NIFEdipine: May enhance the hypotensive effect of Beta-Blockers. NIFEdipine may enhance the negative inotropic effect of Beta-Blockers. Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May diminish the antihypertensive effect of Beta-Blockers. Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Consider therapy modification

Opioids (Anilidopiperidine): May enhance the bradycardic effect of Beta-Blockers. Opioids (Anilidopiperidine) may enhance the hypotensive effect of Beta-Blockers. Monitor therapy

Panobinostat: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of sensitive CYP2D6 substrates when possible, particularly those substrates with a narrow therapeutic index. Consider therapy modification

Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Propafenone: May increase the serum concentration of Beta-Blockers. Propafenone possesses some independent beta blocking activity. Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

QuiNINE: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy

Regorafenib: May enhance the bradycardic effect of Beta-Blockers. Monitor therapy

Reserpine: May enhance the hypotensive effect of Beta-Blockers. Monitor therapy

Rifamycin Derivatives: May decrease the serum concentration of Beta-Blockers. Exceptions: Rifabutin. Monitor therapy

Rivastigmine: May enhance the bradycardic effect of Beta-Blockers. Avoid combination

Ruxolitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Management: Ruxolitinib Canadian product labeling recommends avoiding use with bradycardia-causing agents to the extent possible. Monitor therapy

Selective Serotonin Reuptake Inhibitors: May increase the serum concentration of Beta-Blockers. Exceptions: Citalopram; Escitalopram; FluvoxaMINE. Monitor therapy

Sulfonylureas: Beta-Blockers may enhance the hypoglycemic effect of Sulfonylureas. Cardioselective beta-blockers (eg, acebutolol, atenolol, metoprolol, and penbutolol) may be safer than nonselective beta-blockers. All beta-blockers appear to mask tachycardia as an initial symptom of hypoglycemia. Ophthalmic beta-blockers are probably associated with lower risk than systemic agents. Monitor therapy

Terlipressin: May enhance the bradycardic effect of Bradycardia-Causing Agents. Monitor therapy

Theophylline Derivatives: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Theophylline Derivatives. Management: Monitor for reduced theophylline efficacy during concomitant use with any beta-blocker. Beta-1 selective agents are less likely to antagonize theophylline than nonselective agents, but selectivity may be lost at higher doses. Monitor therapy

Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Monitor therapy

Yohimbine: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Adverse Reactions

Frequency not always defined.

Cardiovascular: Hypotension (1% to 27%), bradycardia (2% to 16%), first degree atrioventricular block (5%), arterial insufficiency (usually Raynaud type: 1%), cardiac failure (1%), cerebrovascular accident (1%), cold extremities (1%), palpitations (1%), peripheral edema (1%), claudication

Central nervous system: Dizziness (2% to 10%), fatigue (1% to 10%), depression (>2% to 5%), vertigo (≤2%), confusion, disturbed sleep, hallucination, headache, insomnia, nightmares, temporary amnesia

Dermatology: Pruritus (5%), rash (>2% to 5%), exacerbation of psoriasis, skin photosensitivity

Endocrine & metabolic: Decreased libido, unstable diabetes

Gastrointestinal: Diarrhea (>2% to 5%), constipation (1%), flatulence (1%), heartburn (1%), stomach pain (1%), xerostomia (1%), nausea (≤1%), vomiting

Neuromuscular & skeletal: Musculoskeletal pain

Ophthalmic: Blurred vision, visual disturbance

Otic: Tinnitus

Respiratory: Dyspnea (≤3%), bronchospasm (1%), wheezing (1%), rhinitis

Miscellaneous: Accidental injury (1%)

<1%, postmarketing and/or case reports: Abdominal pain, agranulocytosis, alopecia (reversible), anxiety, arthralgia, arthritis, chest pain, decreased HDL cholesterol, diaphoresis, drowsiness, dry eye syndrome, gangrene of skin or other tissue, hepatic insufficiency, hepatitis, impotence, increased lactate dehydrogenase, increased serum alkaline phosphatase, increased serum transaminases, increased serum triglycerides, jaundice, nervousness, paresthesia, Peyronie's disease, retroperitoneal fibrosis, syncope, taste disorder, weight gain

ALERT: U.S. Boxed Warning

Ischemic heart disease:

Following abrupt cessation of therapy with certain beta-blocking agents, exacerbations of angina pectoris and, in some cases, myocardial infarction (MI) have occurred. When discontinuing chronically administered metoprolol, particularly in patients with ischemic heart disease, gradually reduce the dosage over a period of 1 to 2 weeks and carefully monitor the patient. If angina markedly worsens or acute coronary insufficiency develops, reinstate metoprolol administration promptly, at least temporarily, and take other measures appropriate for the management of unstable angina. Warn patients against interruption or discontinuation of therapy without their health care provider's advice. Because coronary artery disease is common and may be unrecognized, it may be prudent not to discontinue metoprolol therapy abruptly, even in patients treated only for hypertension.

Warnings/Precautions

Concerns related to adverse events:

• Anaphylactic reactions: Use caution with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to repeated allergen challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects.

• Atrioventricular (AV) block: Metoprolol commonly produces mild first-degree heart block. Metoprolol may also produce severe first-, second-, or third-degree heart block. Patients with acute myocardial infarction (especially right ventricular myocardial infarction) have a high risk of developing heart block of varying degrees. If severe heart block occurs, metoprolol should be discontinued and measures to increase heart rate should be employed.

• Bradycardia: Bradycardia, including sinus pause, heart block, and cardiac arrest, may occur. Patients with first-degree AV block, sinus node dysfunction, or conduction disorders may be at increased risk. Monitor heart rate and rhythm; if severe bradycardia occurs, reduce dose or discontinue therapy.

• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery, driving).

• Hypotension: Symptomatic hypotension may occur with use.

Disease-related concerns:

• Bronchospastic disease: In general, patients with bronchospastic disease should not receive beta-blockers; however, metoprolol, with B1 selectivity, has been used cautiously with close monitoring.

• Conduction abnormality: Consider preexisting conditions such as sick sinus syndrome before initiating.

• Diabetes: Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.

• Heart failure: Use with caution in patients with compensated heart failure; monitor for a worsening of heart failure (only the ER formulation is indicated for use in heart failure). May need to increase diuretics and wait until clinically stable to advance dose to target.

• Hepatic impairment: Use with caution in patients with hepatic impairment.

• Myasthenia gravis: Use beta-blockers with caution in patients with myasthenia gravis.

• Peripheral vascular disease (PVD) and Raynaud disease: May precipitate or aggravate symptoms of arterial insufficiency in patients with PVD and Raynaud disease. Use with caution and monitor for progression of arterial obstruction.

• Pheochromocytoma (untreated): Adequate alpha-blockade is required prior to use of any beta-blocker.

• Prinzmetal variant angina: Beta-blockers without alpha1-adrenergic receptor blocking activity should be avoided in patients with Prinzmetal variant angina because unopposed alpha1-adrenergic receptors mediate coronary vasoconstriction and can worsen anginal symptoms (Mayer 1998).

• Psoriasis: Beta-blocker use has been associated with induction or exacerbation of psoriasis, but cause and effect have not been firmly established.

• Supraventricular tachycardia (SVT): If antidromic atrioventricular reentrant tachycardia (AVRT) or pre-excited atrial fibrillation is suspected, avoid AV node-specific blocking drugs (eg, adenosine, diltiazem, verapamil, digoxin, beta-blockers). For these types of SVT enhanced antegrade conduction from atria to ventricles may occur through an accessory pathway leading to ventricular arrhythmias if the AV node is blocked. It is safe to use AV node-specific blocking drugs for orthodromic AVRT because antegrade conduction occurs through the AV node and only retrograde conduction (from ventricles to atria) occurs through the accessory pathway.

• Thyroid disease: May mask signs of hyperthyroidism (eg, tachycardia). If hyperthyroidism is suspected, carefully manage and monitor; abrupt withdrawal may exacerbate symptoms of hyperthyroidism or precipitate thyroid storm. Alterations in thyroid function tests may be observed.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Dosage form specific issues:

• Switching dosage forms: The conversion ratio for immediate release (metoprolol tartrate) and extended release (metoprolol succinate) is 1:1, therefore the same total daily dose of metoprolol should be used when switching formulations. However, metoprolol tartrate is typically administered in 2 to 3 divided daily doses and metoprolol succinate is administered once daily.

Special populations:

• Elderly: Bradycardia may be observed more frequently in elderly patients (>65 years of age); dosage reductions may be necessary.

Other warnings/precautions:

• Abrupt withdrawal: [US Boxed Warning]: Beta-blocker therapy should not be withdrawn abruptly (particularly in patients with CAD), but gradually tapered over 1 to 2 weeks to avoid acute tachycardia, hypertension, and/or ischemia. Severe exacerbation of angina, ventricular arrhythmias, and myocardial infarction (MI) have been reported following abrupt withdrawal of beta-blocker therapy. Temporary but prompt resumption of beta-blocker therapy may be indicated with worsening of angina or acute coronary insufficiency.

• Major surgery: Chronic beta-blocker therapy should not be routinely withdrawn prior to major surgery.

Monitoring Parameters

Acute cardiac treatment: Monitor ECG, heart rate, and blood pressure with IV administration; heart rate, rhythm, and blood pressure with oral administration.

IV use in a nonemergency situation: Necessary monitoring for surgical patients who are unable to take oral beta-blockers (because of prolonged ileus) has not been defined. Some institutions require monitoring of baseline and postinfusion heart rate and blood pressure when a patient's response to beta-blockade has not been characterized (ie, the patient's initial dose or following a change in dose). Consult individual institutional policies and procedures.

Hypertension: The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (ACC/AHA [Whelton 2017]):

Confirmed hypertension and known CVD or 10-year ASCVD risk ≥10%: Target blood pressure <130/80 mm Hg is recommended.

Confirmed hypertension without markers of increased ASCVD risk: Target blood pressure <130/80 mm Hg may be reasonable.

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies. Metoprolol and the metabolite alpha-hydroxymetoprolol cross the placenta and can be detected in cord blood (Lindeberg 1987; Ryu 2016).

Adverse events, such as fetal/neonatal bradycardia, hypoglycemia, and reduced birth weight, have been observed following in utero exposure to beta-blockers as a class. Adequate facilities for monitoring infants at birth is generally recommended. The pharmacokinetics of metoprolol may be changed during pregnancy; the degree of changes may be dependent upon maternal CYP2D6 genotype (Ryu 2016).

Untreated chronic maternal hypertension and preeclampsia are also associated with adverse events in the fetus, infant, and mother (ACOG 2015; Magee 2014). Recommendations for the treatment of hypertension in pregnancy vary by guideline, but use of metoprolol may be considered (ESC [Regitz-Zagrosek 2011]; Magee 2014). Heart failure, peripartum cardiomyopathy, and valvular heart disease may cause severe complications in pregnant women; metoprolol is recommended when use of a beta-blocker is indicated (AHA/ACC [Nishimura 2014]; ESC [Regitz-Zagrosek 2011]; Sliwa 2010). Use of metoprolol may be considered for some arrhythmias, including SVT, when a beta-blocker is needed (ACC/AHA/HRS [Page 2016]; ESC [Regitz-Zagrosek 2011]). Use of metoprolol may be considered if migraine prophylaxis is needed in a pregnant woman (Pringsheim 2012).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience diarrhea, loss of strength and energy, nausea, or vomiting. Have patient report immediately to prescriber depression, severe dizziness, passing out, angina, abnormal heartbeat, bradycardia, shortness of breath, excessive weight gain, or swelling of arms or legs(HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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