From the Guidelines
Metoprolol can cause nightmares as a side effect, and switching to bisoprolol is a reasonable alternative. Metoprolol CR 47.5mg can be converted to bisoprolol 5mg once daily, as bisoprolol is a beta-1 selective agent with a long half-life, providing 24-hour efficacy 1. Nightmares and sleep disturbances are known adverse effects of lipophilic beta-blockers like metoprolol, which more readily cross the blood-brain barrier. Bisoprolol is more hydrophilic (less lipophilic) and therefore less likely to penetrate the central nervous system, potentially reducing these neuropsychiatric side effects. When switching, no washout period is needed; the patient can start bisoprolol the day after the last metoprolol dose. Monitor the patient's blood pressure and heart rate after switching to ensure adequate beta-blockade is maintained. If the patient experiences any dizziness, significant changes in blood pressure, or heart rate during the transition, dose adjustment may be necessary. The nightmares should resolve within a few days to weeks after discontinuing metoprolol. Some key properties of beta blockers, including metoprolol and bisoprolol, are outlined in Table 15 from the ACC/AHA 2007 guidelines, which lists the usual dose for angina as 50 to 200 mg twice daily for metoprolol and 10 mg per day for bisoprolol 1. However, the European Society of Cardiology guidelines suggest a target dose of bisoprolol 10 mg o.d. for full anti-anginal effects 1. Given the patient's current dose of metoprolol CR 47.5mg, a conversion to bisoprolol 5mg once daily is a reasonable approach, considering the patient's potential sensitivity to beta-blocker side effects. It is essential to prioritize the patient's quality of life and adjust the treatment plan accordingly, while also ensuring adequate control of their cardiovascular condition. The patient should be closely monitored for any changes in their condition, and the treatment plan should be adjusted as needed to minimize adverse effects and optimize outcomes.
From the FDA Drug Label
Headache, nightmares, and insomnia have also been reported.
The patient's nightmares could be caused by metoprolol, as nightmares are listed as a potential adverse reaction. If metoprolol is suspected to be the cause, switching to bisoprolol may be considered. However, the dose of bisoprolol is not directly stated in the provided drug label for metoprolol, and therefore, no specific dose can be recommended 2.
From the Research
Metoprolol and Nightmares
- Metoprolol has been associated with central nervous system (CNS) side effects, including nightmares, due to its lipophilic properties, which allow it to cross the blood-brain barrier 3, 4, 5, 6, 7.
- The risk of beta-blocker CNS side effects is directly associated with the lipophilic property of the drug 4.
- Studies have reported that metoprolol can cause vivid dreams, hallucinations, sleep disturbances, and psychosis, particularly in elderly patients 4, 5, 6, 7.
Switching to Bisoprolol
- Bisoprolol is a beta-blocker with a more selective beta-1 blockade and less lipophilicity compared to metoprolol, which may reduce the risk of CNS side effects 3.
- Bisoprolol has been shown to be effective in reducing all-cause death and sudden death in patients with heart failure, and may be a suitable alternative to metoprolol 3.
- The equivalent dose of bisoprolol to metoprolol 47.5mg CR is not explicitly stated in the provided studies, but bisoprolol is often started at a dose of 2.5-5mg daily and titrated as needed 3.
Dose Conversion
- The dose conversion from metoprolol to bisoprolol should be done under medical supervision, taking into account the individual patient's response and medical history.
- It is essential to monitor the patient for any adverse effects or changes in their condition after switching to bisoprolol 3, 4, 5, 6, 7.