What are the special considerations when stopping metoprolol (beta blocker) in an elderly person?

From the Guidelines

Stopping metoprolol in elderly patients requires gradual tapering over 2-4 weeks rather than abrupt discontinuation. The recommended approach is to reduce the dose by 25-50% every 1-2 weeks while monitoring for symptoms of withdrawal such as increased heart rate, elevated blood pressure, worsening angina, or heart failure exacerbation 1. For example, if an elderly patient is taking metoprolol 50mg twice daily, consider reducing to 25mg twice daily for 1-2 weeks, then 25mg once daily for another 1-2 weeks before stopping completely. Close monitoring is essential during this process, with blood pressure and heart rate checks at each dose reduction. Elderly patients are particularly vulnerable to withdrawal effects due to age-related changes in drug metabolism, reduced physiological reserve, and often multiple comorbidities, as highlighted in a study on secondary prevention of atherosclerotic cardiovascular disease in older adults 1. Abrupt discontinuation can trigger rebound tachycardia, hypertension, and potentially life-threatening cardiac events including myocardial infarction due to sudden sympathetic nervous system activation. If the patient experiences concerning symptoms during tapering, slowing the tapering schedule or temporarily returning to the previous dose may be necessary. Patients should be educated to immediately report chest pain, significant palpitations, shortness of breath, or dizziness during the tapering process.

Some key considerations when stopping metoprolol in elderly patients include:

• Age-related changes in drug metabolism and physiology
• Presence of multiple comorbidities
• Risk of withdrawal effects, such as rebound tachycardia and hypertension
• Need for close monitoring and gradual tapering
• Importance of patient education and reporting of symptoms As noted in a recent review by the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy, deprescribing, including the withdrawal of beta-blockers like metoprolol, requires careful planning to minimize adverse effects and improve outcomes 1.

From the FDA Drug Label

The geriatric population may show slightly higher plasma concentrations of metoprolol as a combined result of a decreased metabolism of the drug in elderly population and a decreased hepatic blood flow. In general, use a low initial starting dose in elderly patients given their greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

When stopping metoprolol in an elderly person, special considerations include:

• The potential for higher plasma concentrations of metoprolol due to decreased metabolism and hepatic blood flow in the elderly population 2
• The need to consider the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy in elderly patients 2 It is essential to exercise caution and carefully monitor the patient's condition when stopping metoprolol in an elderly person.

From the Research

Special Considerations for Stopping Metoprolol in Elderly Persons

When considering stopping metoprolol in an elderly person, several factors should be taken into account:

• The risk of rebound effects, such as increased heart rate and blood pressure, which can occur after abrupt withdrawal of the drug 3
• The potential for withdrawal-like symptoms, such as fatigue, dizziness, and headache, which have been reported in some patients after stopping metoprolol 3
• The need for gradual tapering of the dose to minimize the risk of adverse effects, as recommended in the study by 3
• The importance of monitoring the patient's blood pressure and heart rate closely after stopping metoprolol, as these parameters can change rapidly 3

Pharmacological Properties of Metoprolol

Metoprolol is a beta1-selective adrenoceptor blocking drug with a long duration of action, making it suitable for twice-daily administration 4. It is similar in efficacy to other beta-adrenoceptor blocking drugs in angina pectoris and essential hypertension, when given in equiactive beta-blocking dosages 4.

Efficacy and Safety in Elderly Patients

Metoprolol has been shown to be effective and well-tolerated in elderly patients with hypertension, with a significant reduction in blood pressure and a low incidence of side effects 5. The drug has also been found to be beneficial in patients with chronic heart failure, reducing mortality and improving clinical status 6.

Dosage and Administration

The dosage of metoprolol should be individualized, and the drug should be initiated at a low dose and gradually increased as needed and as tolerated 7. The use of a slow-release formulation can help to maintain satisfactory control with once-daily dosing 7.