Metoprolol

Metoprolol is a cardioselective beta-1 adrenergic blocker that competitively blocks beta-1 receptors primarily located in the heart, reducing heart rate, myocardial contractility, and cardiac output. It also reduces renin release from the kidneys, contributing to its antihypertensive effect. At higher doses, it may also block beta-2 receptors.

Adult

Hypertension: Initial 25-100 mg once daily (succinate ER) or 50-100 mg daily in 1-2 divided doses (tartrate IR). Titrate every 1-2 weeks to desired effect, typically 100-200 mg/day. Angina: Initial 50 mg twice daily (tartrate IR) or 100 mg once daily (succinate ER). Titrate to response, typically 100-200 mg/day.…

Pediatric

Hypertension (≥6 years): Initial 0.5-1 mg/kg once daily (succinate ER), max 50 mg/day. Titrate up to 2 mg/kg/day (max 200 mg/day).

Renal adjustment

No dose adjustment typically required for renal impairment (including hemodialysis).

Hepatic adjustment

Dose reduction may be necessary in severe hepatic impairment (e.g., cirrhosis). Start with lower doses and titrate carefully.

Geriatric

Start with lower doses (e.g., 25 mg once daily) and titrate slowly due to increased sensitivity and potential for adverse effects (bradycardia, hypotension).

Max dose

400 mg/day (for metoprolol tartrate); 200 mg/day (for metoprolol succinate ER)

• Sinus bradycardia (<45-50 bpm)
• Second or third-degree atrioventricular (AV) block
• Sick sinus syndrome (unless permanent pacemaker in place)
• Cardiogenic shock
• Decompensated heart failure
• Severe peripheral arterial disease
• Untreated pheochromocytoma
• Severe bronchial asthma or severe COPD
• Hypersensitivity to metoprolol or other beta-blockers
• acute myocardial infarction (contraindicated if heart rate <45 bpm, heart block >first-degree, SBP <100 mmHg, or moderate-to-severe heart failure)
• abrupt discontinuation (withdrawal syndrome)
• Asthma
• Peripheral vascular disease
• Hypoglycemia
• AV block (grade 2-3)
• acute heart failure episode (should be stopped)
• worsening of heart failure upon introduction
• asymptomatic left ventricular dysfunction
• Signs of acute heart failure
• Evidence of a low-output state
• Increased risk for cardiogenic shock
• Bradycardia (>60 beats/min for IV use, otherwise a contraindication)
• PR interval >0.24 s
• Second- or third-degree heart block
• Active asthma
• Reactive airway disease
• Severe HF or severely compromised LV function
• Contraindicated in high-grade heart block