What is the recommended dose and frequency of Metoprolol (beta blocker)?

From the Guidelines

Metoprolol should be prescribed at an initial dose of 12.5-25 mg once daily for heart failure, with a target dose of 200 mg daily if tolerated, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The dosage and frequency of metoprolol may vary depending on the specific condition being treated.

• For heart failure, the initial dose is typically 12.5-25 mg once daily, with a target dose of 200 mg daily if tolerated, as seen in the 2022 AHA/ACC/HFSA guideline 1.
• The extended-release formulation (metoprolol succinate) is dosed once daily, while the immediate-release form (metoprolol tartrate) requires twice-daily dosing for optimal effect.
• Dosage adjustments are necessary for patients with liver impairment, as metoprolol is primarily metabolized by the liver. The medication works by blocking beta-1 adrenergic receptors, reducing heart rate and blood pressure by decreasing cardiac output and the release of renin from the kidneys. Common side effects include fatigue, dizziness, and bradycardia, which often improve with continued use or dose adjustment. Metoprolol should be taken consistently at the same times each day, and patients should never stop taking it abruptly as this can trigger rebound hypertension or worsening angina, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital. Such treatment should be initiated in a coronary care or similar unit immediately after the patient’s hemodynamic condition has stabilized Begin treatment in this early phase with the intravenous administration of three bolus injections of 5 mg of metoprolol tartrate injection each; give the injections at approximately 2-minute intervals. During the intravenous administration of metoprolol tartrate injection, monitor blood pressure, heart rate, and electrocardiogram In patients who tolerate the full intravenous dose (15 mg), initiate metoprolol tartrate tablets, 50 mg every 6 hours, 15 minutes after the last intravenous dose and continued for 48 hours. Thereafter, the maintenance dosage is 100 mg orally twice daily Start patients who appear not to tolerate the full intravenous on metoprolol tartrate tablets either 25 mg or 50 mg every 6 hours (depending on the degree of intolerance) 15 minutes after the last intravenous dose or as soon as their clinical condition allows. The recommended metoprolol dose and frequency are as follows:

• Initial dose: 3 bolus injections of 5 mg of metoprolol tartrate injection each, given at approximately 2-minute intervals
• Post-intravenous dose: 50 mg every 6 hours for 48 hours, then 100 mg orally twice daily for maintenance
• Alternative dose for intolerance: 25 mg or 50 mg every 6 hours, depending on the degree of intolerance 2

From the Research

Metoprolol Dose and Frequency

• The optimal dose and frequency of metoprolol can vary depending on the specific condition being treated and the individual patient's response to the medication 3.
• In the treatment of hypertension, metoprolol can be administered once daily, with doses ranging from 100 mg to 200 mg 3.
• A study comparing metoprolol with carvedilol in patients with stable chronic heart failure found that the two medications had similar effects on survival, with no conclusive association between all-cause mortality and treatment with either medication 4.
• Another study compared the effectiveness of different beta blockers, including metoprolol, in reducing the risk of rehospitalization in adults with heart failure, and found that the adjusted risks of readmission were not significantly different for metoprolol tartrate compared to atenolol or carvedilol 5.
• A meta-analysis of carvedilol versus beta 1 selective beta-blockers, including metoprolol, found that carvedilol significantly reduced all-cause mortality in patients with systolic heart failure, but the comparison with metoprolol was not specifically highlighted 6.
• The choice of beta blocker, including metoprolol, is important, as benefit is not a class-effect, and the presence of intrinsic sympathomimetic activity can diminish efficacy 7.

Key Considerations

• Metoprolol can be administered in various doses and frequencies, depending on the specific condition being treated and the individual patient's response to the medication 3.
• The medication has been shown to be effective in reducing blood pressure and improving outcomes in patients with heart failure, but the optimal dose and frequency may vary depending on the specific context 3, 4, 5.
• The choice of beta blocker, including metoprolol, should be based on individual patient characteristics and the specific condition being treated, as the benefits and risks of different medications can vary 7, 6.