From the Guidelines
Metoprolol succinate is typically started at 25-50 mg once daily for most indications, with gradual titration as needed up to a maximum of 200 mg daily, as recommended by 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. The dosing of metoprolol succinate can vary depending on the specific indication, such as hypertension, heart failure, or post-myocardial infarction.
- For hypertension, the usual maintenance dose is 50-100 mg once daily.
- For heart failure, treatment often begins at 25 mg daily and doubles every two weeks as tolerated to a target dose of 200 mg daily, as supported by the MERIT-HF trial 1.
- For post-myocardial infarction, the recommended dose is not explicitly stated in the provided guidelines, but metoprolol succinate is an extended-release formulation that should be taken once daily, preferably in the morning, with or without food, and tablets should be swallowed whole without crushing or chewing. Key considerations in metoprolol succinate dosing include:
- Gradual titration to minimize adverse effects and optimize efficacy
- Regular monitoring of blood pressure, heart rate, and clinical status to guide dose adjustments
- Potential need for dose adjustments in patients with hepatic impairment or the elderly
- Importance of not abruptly discontinuing metoprolol succinate, as this can lead to rebound hypertension or worsening angina; dosage should be gradually reduced over 1-2 weeks when discontinuation is necessary, as emphasized in the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION ... 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 dosing for metoprolol (metoprolol succinate) is not directly stated in the provided drug label, as it refers to metoprolol tartrate. However, based on the information provided for metoprolol tartrate, the maintenance dosage is 100 mg orally twice daily after the initial treatment. 2
From the Research
Metoprolol Succinate Dosing
- The recommended dosing for metoprolol succinate varies depending on the condition being treated 3, 4, 5, 6, 7.
- For patients with chronic heart failure, the initial dose is typically 12.5 to 25 mg once daily, with gradual increases at 2-weekly intervals until the target dosage of 200 mg once daily or maximal tolerated dosage is reached 3, 4.
- In the MERIT-HF trial, treatment with metoprolol CR/XL was initiated at a low dosage of 12.5 to 25 mg once daily and gradually increased at 2-weekly intervals until the target dosage (200 mg once daily) or maximal tolerated dosage had been attained in patients receiving standard therapy for heart failure 3.
- The Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) study demonstrated that ER metoprolol succinate reduced the relative risk of all-cause mortality by 34% versus placebo, with a target dose of 200 mg once daily 4, 7.
- For patients with hypertension, a 100-mg metoprolol controlled/extended-release tablet contains 95 mg of metoprolol succinate and is considered to have equivalent activity of 100 mg metoprolol tartrate 5.
- Extended-release metoprolol succinate is designed to deliver metoprolol succinate at a near constant rate for approximately 20 hours, independent of food intake and gastrointestinal pH, allowing for once-daily dosing 6, 7.
Key Considerations
- The dosing of metoprolol succinate should be individualized and titrated to achieve the desired therapeutic effect while minimizing adverse effects 3, 4, 5, 6, 7.
- Patients should be closely monitored for signs of adverse effects, such as bradycardia, hypotension, and worsening heart failure, and the dose adjusted accordingly 3, 4, 7.