Is it safe to administer metoprolol (beta blocker) to a patient with hypotension?

From the Guidelines

Administering metoprolol to a patient with a blood pressure of 98/62 is not recommended due to the risk of worsening hypotension. Metoprolol, a beta-blocker, works by blocking beta-adrenergic receptors, which reduces heart rate and contractility, ultimately lowering blood pressure. In a patient who already has hypotension (low blood pressure), giving metoprolol could worsen their condition by further decreasing blood pressure, potentially leading to inadequate organ perfusion, dizziness, syncope, or even shock. According to 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, beta blockers are not recommended as first-line agents unless the patient has ischemic heart disease or heart failure. Additionally, the guideline suggests that beta blockers should be used with caution in patients with hypotension, and the dose should be titrated slowly while monitoring blood pressure response. The ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 also recommend careful dose up-titration of beta blockers, with visits every 2–4 weeks to up-titrate the dose, and not increasing the dose if signs of worsening heart failure, symptomatic hypotension, or excessive bradycardia are present 1. Therefore, in this case, it is not recommended to administer metoprolol 25 mg to a patient with a blood pressure of 98/62. Instead, alternative medications or a lower dose of metoprolol (such as 12.5 mg twice daily) could be considered, with close monitoring of blood pressure response. Some key points to consider when administering beta blockers to patients with hypotension include:

• Starting with a lower dose and titrating slowly
• Monitoring blood pressure response closely
• Avoiding beta blockers in patients with severe hypotension or those who are at risk of cardiogenic shock
• Considering alternative medications if the patient has indications for beta-blockade but cannot tolerate metoprolol due to hypotension.

From the FDA Drug Label

OVERDOSAGE ... Potential signs and symptoms associated with overdosage with metoprolol are ... hypotension Management ... Hypotension Administer a vasopressor, e.g., norepinephrine or dopamine.

The administration of metoprolol to a patient with hypotension (BP 98/62) is not recommended as metoprolol can cause or worsen hypotension.

• Hypotension is a potential sign of metoprolol overdose.
• The management of metoprolol-induced hypotension involves administering a vasopressor.
• Given that metoprolol can exacerbate hypotension, it is not safe to administer metoprolol 25 mg to a patient with a blood pressure of 98/62. 2

From the Research

Administration of Metoprolol in Hypotension

• The administration of metoprolol, a beta blocker, to a patient with hypotension (low blood pressure) is not recommended as it can further decrease blood pressure 3, 4, 5, 6, 7.
• Metoprolol is typically used to treat high blood pressure, angina, and certain heart-related conditions, but it is not indicated for hypotension.
• In patients with hypotension, the goal is to increase blood pressure, not decrease it, and metoprolol can have the opposite effect.

Alternative Treatments for Hypotension

• Midodrine, an alpha-1 adrenergic agonist, is often used to treat orthostatic hypotension, a type of low blood pressure that occurs when standing up 4, 6, 7.
• Fludrocortisone, a mineralocorticoid analog, is also used to treat orthostatic hypotension, but it may have a higher risk of hospitalizations compared to midodrine 5.
• Droxidopa, a synthetic precursor to norepinephrine, is another option for treating orthostatic hypotension, and it may be used in combination with midodrine for refractory cases 6.
• Non-pharmacological strategies, such as increasing fluid and salt intake, avoiding large meals, and exercising regularly, can also help manage hypotension 3.

Considerations for Metoprolol Administration

• If a patient is already taking metoprolol for another condition, such as high blood pressure or angina, and develops hypotension, the dosage may need to be adjusted or the medication discontinued 3, 4, 5, 6, 7.
• It is essential to monitor blood pressure closely when administering metoprolol, especially in patients with hypotension, to avoid exacerbating the condition.
• A healthcare professional should be consulted before administering metoprolol to a patient with hypotension, as they can assess the individual's specific needs and provide guidance on the best course of treatment.