Uses
Hypertension
Management of hypertension (alone or in combination with other classes of antihypertensive agents).
One of several preferred initial therapies in hypertensive patients with ischemic heart disease, heart failure, or diabetes mellitus.
Can be used as monotherapy for initial management of uncomplicated hypertension; however, thiazide diuretics are preferrred by JNC 7.
Angina
Management of chronic stable angina pectoris.
A component of the standard therapeutic measures in the management of unstable angina or non-ST-segment elevation/non-Q-wave MI.
AMI
Secondary prevention following AMI to reduce the risk of reinfarction and mortality.
Supraventricular Tachyarrhythmias
Treatment of atrial fibrillation or flutter† following AMI when clinical left ventricular dysfunction, bronchospastic disease, and AV block are not present.
Treatment of ectopic or multifocal (chaotic) atrial tachycardia† in patients with preserved left ventricular function.
Treatment of paroxysmal supraventricular tachycardia† that is refractory to vagal maneuvers, IV adenosine, AV nodal blocking agents, and electrical cardioversion therapy or in patients for whom such therapy is not feasible or desirable.
Treatment of symptomatic junctional tachycardia† not associated with a readily identifiable and potentially correctable underlying cause.
Ventricular Tachyarrhythmias
Reduction of the incidence of ventricular fibrillation† associated with myocardial ischemia or infarction.
Treatment of hemodynamically stable, sustained polymorphic ventricular tachycardia† following AMI.
CHF
Management of mild to moderately severe (NYHA class II or III) heart failure of ischemic, hypertensive, or cardiomyopathic origin (in conjunction with ACE inhibitors, diuretics, and cardiac glycosides).
Vascular Headache
Prophylaxis of migraine headache†; not recommended for the treatment of a migraine attack that has already started.
Dosage and Administration
General
- β1-Adrenergic blocking selectivity diminishes as dosage is increased.
- If long-term therapy is discontinued, reduce dosage gradually over a period of 1–2 weeks. (See Abrupt Withdrawal of Therapy under Cautions.)
Hypertension
- Metoprolol/hydrochlorothiazide fixed combination is not recommended for initial combination therapy; adjust initial and subsequent dosages by administering each drug separately.
Administration
Administer orally or by IV injection.
Oral Administration
Conventional Tablets
Administer metoprolol tartrate conventional tablets daily as a single dose or in divided doses, with or immediately following meals.
Extended-release Tablets
Administer metoprolol succinate extended-release tablets daily as a single dose.
Extended-release tablets are scored and can be divided. However, swallow tablet or half tablet whole; do not chew or crush.
When switching from conventional tablets to extended-release tablets, administer the same daily dosage.
IV Administration
For solution and drug compatibility information, see Compatibility under Stability.
Monitor heart rate, BP, and ECG during IV therapy.
Discontinue IV therapy when therapeutic efficacy is achieved (e.g., slowing of ventricular rate in atrial fibrillation) or if systolic BP or heart rate declines to <100 mm Hg or 50 bpm, respectively. Discontinue therapy in patients with severe intolerance to IV therapy.
Rate of Administration
Administer as a rapid IV injection. Administer over 1–2 minutes for the management of unstable angina or non-ST-segment elevation/non-Q-wave MI†.
Dosage
Available as metoprolol tartrate and metoprolol succinate; dosage expressed in terms of the tartrate.
Pediatric Patients
Hypertension
Oral
Some experts recommend an initial dosage of 1–2 mg/kg daily given in 2 divided doses. Increase dosage as necessary up to a maximum dosage of 6 mg/kg (up to 200 mg) daily given in 2 divided doses.†
Adults
Hypertension
Oral
Initially, 50–100 mg given once daily (extended-release tablets) or in single or divided doses daily (conventional tablets). Increase dosage at weekly (or longer) intervals until optimum effect is achieved.
If satisfactory BP response is not maintained throughout the day, larger doses, more frequent administration, or use of extended-release tablets may be required.
Angina
Long-term Management
Oral
Initially, 100 mg given once daily (extended-release tablets) or in 2 divided doses daily (conventional tablets). Increase dosage at weekly intervals until optimum response is obtained or pronounced slowing of heart rate occurs.
Usual maintenance dosage is 100–400 mg daily.
Unstable Angina or Non-ST-Segment Elevation MI
IV, then Oral
Patients at high risk for ischemic events should receive IV loading dose followed by conversion to an oral regimen; oral therapy is recommended for lower risk patients.†
5 mg IV every 5 minutes up to a total of 15 mg. If IV dose is tolerated, 25–50 mg orally, initiated 15 minutes after the last IV dose and repeated every 6 hours for 48 hours, followed by 100 mg twice daily. Target resting heart rate is 50–60 bpm in the absence of dose-limiting adverse effects.†
AMI
As soon as clinical condition allows, administer oral therapy (conventional tablets) to patients who have contraindications to or do not tolerate IV therapy during the early phase of definite or suspected AMI or to patients in whom therapy is delayed.
Early Treatment.
IV, then Oral
2.5–5 mg IV every 2–5 minutes up to a total of 15 mg over 10–15 minutes. If total IV dose is tolerated, 50 mg orally, initiated 15 minutes after the last IV dose and repeated every 6 hours for 48 hours, followed by 100 mg twice daily. If total IV dose is not tolerated, 25 or 50 mg (depending on the degree of intolerance) orally every 6 hours beginning 15 minutes after the last IV dose or as soon as clinical condition allows.
Late Treatment
Oral
100 mg twice daily for at least 3 months.
Supraventricular Tachyarrhythmias
Atrial Fibrillation.
IV, then Oral
2.5–5 mg IV every 2–5 minutes as necessary to control rate, up to a total of 15 mg over 10–15 minutes. Then, 50 mg orally twice daily for 24 hours, starting 15 minutes after the last IV dose; increase to 100 mg twice daily, as tolerated. Alternatively, 25–100 mg orally twice daily for long-term control.†
CHF
Oral
Initially, 25 mg (extended-release tablets) once daily in adults with NYHA class II heart failure. In patients with more severe heart failure, use an initial dosage of 12.5 mg (extended-release tablets) once daily. Double the dosage every 2 weeks to a dosage of 200 mg or until highest tolerated dosage is reached.
Some experts recommend initiation of therapy with 12.5 mg (extended-release tablets) daily or 6.25 mg (conventional tablets) twice daily for 2–4 weeks. If tolerated, increase to 25 mg daily for 2–4 weeks; subsequent dosages can be doubled every 2–4 weeks.
If deterioration occurs during titration, increase dosage of concurrent diuretic and decrease dosage of metoprolol or temporarily discontinue metoprolol. Do not continue dosage titration until symptoms of worsening heart failure have stabilized. Initial difficulty in dosage titration should not preclude subsequent attempts to successfully titrate the dosage.
Reduce dosage in patients with CHF who experience symptomatic bradycardia (e.g., dizziness) or 2nd or 3rd degree heart block.
Vascular Headache
Migraine
Oral
Dosages of 50–300 mg daily have been used in clinical studies; usual effective dosage was 200 mg daily.†
Prescribing Limits
Pediatric Patients
Hypertension
Oral
Maximum 6 mg/kg (up to 200 mg) daily.†
Adults
Hypertension
Oral
Dosages >400 mg (extended-release tablets) and 450 mg (conventional tablets) daily have not been studied.
Angina
Oral
Dosages >400 mg daily have not been studied.
IV
Maximum 15 mg over 15 minutes in patients with unstable angina or non-ST-segment elevation MI†.
AMI
IV
Maximum 15 mg over 10–15 minutes.
Supraventricular Tachyarrhythmias
Atrial FIbrillation.
Oral
Maximum 100 mg twice daily.†
IV
Maximum 15 mg over 10–15 minutes.†
CHF
Oral
Up to 200 mg daily.
Special Populations
Dosage in Hepatic Impairment
Elimination occurs mainly in the liver; dosage reductions may be necessary.
Dosage in Renal Impairment
Dosage adjustments are not required.
Geriatric Patients
Cautious dosage selection recommended; initiate therapy at the lower end of the dosage range.
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