What is the treatment and management for a patient with hypotension currently on metoprolol (beta blocker) 12.5 mg twice daily (BID)?

From the Guidelines

For a patient with low blood pressure who is currently taking metoprolol 12.5 mg twice daily, I recommend reducing or discontinuing the metoprolol dose, as beta-blockers should not be stopped suddenly unless absolutely necessary, but in this case, symptomatic hypotension necessitates a re-evaluation of the treatment plan. Consider decreasing to 6.25 mg twice daily or once daily as a first step, with close monitoring of blood pressure response, as suggested by the European Society of Cardiology guidelines 1. If hypotension persists, complete discontinuation may be necessary. The patient should be monitored frequently during dose adjustments, ideally with home blood pressure measurements. Metoprolol, a beta-blocker, works by blocking beta-adrenergic receptors, reducing heart rate and contractility, which lowers blood pressure. When a patient develops hypotension on this medication, it suggests the blood pressure-lowering effect is excessive for their current physiologic needs. Ensure adequate hydration and assess for other potential causes of hypotension such as dehydration, other medications with hypotensive effects, or underlying conditions.

Some key considerations in managing this patient include:

• Re-evaluating the patient's clinical status, including assessing for signs of congestion, and considering reducing diuretic dose if no signs of congestion are present 1
• Avoiding sudden discontinuation of beta-blockers unless absolutely necessary, due to the risk of rebound increase in myocardial ischemia or infarction and arrhythmias 1
• Considering specialist advice before treatment discontinuation, especially if the patient has a compelling indication for beta-blocker therapy, such as heart failure or post-myocardial infarction 1
• Monitoring the patient's response to dose adjustments, and being prepared to adjust the treatment plan further if necessary, including considering alternative diagnoses, and the potential need for mechanical circulatory support or other advanced therapies 1

From the FDA Drug Label

Management There is no specific antidote In general, patients with acute or recent myocardial infarction may be more hemodynamically unstable than other patients and should be treated accordingly Hypotension Administer a vasopressor, e.g., norepinephrine or dopamine. The patient's low blood pressure while on metoprolol 12.5 mg BID may be managed by administering a vasopressor, such as norepinephrine or dopamine 2.

• The treatment approach should be based on symptomatic management.
• Clinical manifestations of the condition should be managed using modern methods of intensive care.

From the Research

Treatment and Management of Low Blood Pressure with Metoprolol

• The patient is currently taking metoprolol 12.5 mg BID, which is a beta-blocker used to treat hypertension and angina pectoris 3.
• However, the patient is experiencing low blood pressure, which may be a side effect of the medication.
• According to a study published in 1986, metoprolol is generally well tolerated, but temporary fatigue, dizziness, and headache are among the most frequently reported side effects 3.
• Another study published in 1984 found that metoprolol treatment lowered blood pressure and heart rate in patients with essential hypertension, and also reduced sympathetic vasoconstrictor outflow to muscles, which contributed to the blood pressure reduction 4.
• A study published in 2021 found that fludrocortisone, a mineralocorticoid, can be used to treat orthostatic hypotension, which is a condition characterized by a excessive fall in blood pressure while standing 5.
• The treatment and management of low blood pressure with metoprolol may involve adjusting the dosage or switching to a different medication.
• It is also important to monitor the patient's blood pressure and heart rate regularly to ensure that the medication is not causing any adverse effects.
• Additionally, the patient may need to be educated on how to manage their low blood pressure, such as by increasing fluid and salt intake, and avoiding sudden changes in position.

Possible Adjustments to Metoprolol Dosage

• The dosage of metoprolol may need to be adjusted to minimize the risk of low blood pressure.
• A study published in 1976 found that the plasma levels of metoprolol varied significantly between patients, and that the peak drug plasma concentration was reached within 1-3 hours after oral administration 6.
• Another study published in 2016 found that intravenous antihypertensive therapy, including metoprolol, was often used to treat elevated blood pressure in hospitalized patients, but that the use of these medications was not always necessary and may have caused adverse effects 7.
• The patient's dosage of metoprolol may need to be adjusted based on their individual response to the medication, and their blood pressure and heart rate should be monitored regularly to ensure that the medication is not causing any adverse effects.