From the Guidelines
To taper a patient off 25 mg of metoprolol extended release, I recommend a gradual reduction over 2-3 weeks, as abrupt discontinuation can lead to rebound hypertension, increased heart rate, or worsening angina, especially in patients with underlying cardiovascular disease 1.
Tapering Process
The tapering process should start by decreasing the dose to 12.5 mg daily for 7-10 days, then to 12.5 mg every other day for another 7-10 days before discontinuing completely.
- Monitor the patient's blood pressure and heart rate regularly, ideally at least twice weekly, during the tapering period.
- If symptoms like increased heart rate, palpitations, or elevated blood pressure occur during tapering, slow down the process by extending each step to 10-14 days.
Special Considerations
For patients with coronary artery disease or heart failure, an even more gradual taper might be necessary, potentially extending over 4-6 weeks, to minimize the risk of adverse effects 1.
Rationale
The gradual tapering approach allows the body to adjust to decreasing levels of beta-blockade and permits gradual upregulation of beta-receptors that were previously blocked by the medication, reducing the risk of rebound effects 1.
From the FDA Drug Label
When discontinuing chronically administered metoprolol, particularly in patients with coronary artery disease, the dosage should be gradually reduced over a period of 1 to 2 weeks and the patient should be carefully monitored If angina markedly worsens or acute coronary insufficiency develops, metoprolol administration should be reinstated promptly, at least temporarily, and other measures appropriate for the management of unstable angina should be taken.
To taper a patient off 25 mg of metoprolol extended release, gradually reduce the dosage over a period of 1 to 2 weeks. The patient should be carefully monitored for any signs of worsening angina or acute coronary insufficiency. If any of these conditions develop, metoprolol administration should be reinstated promptly. 2
From the Research
Tapering Metoprolol Extended Release
To taper a patient off 25 mg of metoprolol extended release, consider the following steps:
- Gradually reduce the dosage to minimize the risk of adverse withdrawal events, such as enhanced beta adrenergic sensitivity 3
- Initiate the taper by reducing the dose to 12.5 mg once daily, as this is a common starting point for metoprolol CR/XL in patients with heart failure 4, 5
- Continue to taper the dose at 1-2 week intervals, monitoring the patient's response and adjusting the dose as needed
- Consider using a prolonged small dose schedule, where the patient receives a low dose (e.g. 6.25 mg) for an extended period (e.g. 2 weeks) before complete withdrawal, to prevent cardiac hypersensitivity and other adverse events 3
Important Considerations
- Metoprolol extended release is designed to deliver metoprolol succinate at a near constant rate for approximately 20 hours, independent of food intake and gastrointestinal pH 6
- The pharmacokinetics of metoprolol extended release may vary in heart failure patients, and the dose may need to be adjusted accordingly 6
- The efficacy and tolerability of metoprolol CR/XL in heart failure patients has been demonstrated in large-scale clinical trials, including the MERIT-HF study 4, 5
Monitoring and Adjustments
- Monitor the patient's heart rate, blood pressure, and symptoms during the taper, and adjust the dose as needed to prevent adverse events
- Consider using alternative therapies, such as intravenous lipid emulsion and hyperinsulinemia/euglycemia therapy, in cases of metoprolol overdose or severe adverse events 7