From the Guidelines
A patient taking 25mg of metoprolol daily should taper off the medication over 2-3 weeks to minimize the risk of rebound hypertension and other adverse effects. The recommended tapering protocol involves gradually reducing the dose, starting by decreasing to 12.5mg daily for one week, as seen in the dosing ranges for metoprolol succinate which can be between 50–200mg daily 1. Then, the dose can be further reduced to 12.5mg every other day for another week, before completely discontinuing the medication. This gradual reduction is crucial because abrupt discontinuation of beta-blockers like metoprolol can lead to serious complications, including rebound hypertension, increased heart rate, or even precipitate angina or heart attack in patients with underlying coronary artery disease.
Some key points to consider during the tapering process include:
- Monitoring blood pressure and heart rate regularly
- Reporting any significant changes to the healthcare provider
- Being aware of symptoms like chest pain, palpitations, headaches, or significant increases in blood pressure that should prompt immediate medical attention
- Individualizing the tapering schedule based on the patient's specific medical conditions, reason for discontinuation, and response to dose reduction. It's also important to note that metoprolol tartrate and metoprolol succinate have different dosing frequencies, with metoprolol tartrate typically given twice daily and metoprolol succinate given once daily 1. However, the principle of gradual tapering remains the same for both formulations to avoid abrupt cessation, which is a common recommendation for beta-blockers in general 1.
From the Research
Tapering Protocol for Metoprolol
To taper a patient taking 25mg of metoprolol daily, consider the following:
- The study 2 suggests that metoprolol can be initiated at a low dosage of 12.5 to 25 mg once daily and gradually increased at 2-weekly intervals.
- However, for tapering, a gradual reduction in dosage is recommended to prevent withdrawal symptoms.
- A study on propranolol 3 found that tapering the dosage over 6 to 9 days or reducing to a prolonged small dose (30 mg daily) for 2 weeks before complete withdrawal can prevent cardiac hypersensitivity and other adverse events.
- Although there is no direct evidence on tapering metoprolol, a study 4 comparing withdrawal phenomena after propranolol, metoprolol, and pindolol suggests that metoprolol withdrawal can cause an overshoot of heart rate.
Recommended Tapering Schedule
Based on the available evidence, a possible tapering schedule for metoprolol could be:
- Reduce the daily dosage by 12.5 mg every 2 weeks until the patient is taking 12.5 mg daily.
- Then, reduce the dosage to 6.25 mg daily (if possible) for 1-2 weeks before complete withdrawal.
- Monitor the patient closely for any signs of withdrawal symptoms, such as increased heart rate or blood pressure, and adjust the tapering schedule as needed.
Important Considerations
- The tapering schedule may need to be adjusted based on the individual patient's response and medical history.
- It is essential to monitor the patient's vital signs, symptoms, and electrocardiogram (if necessary) during the tapering process.
- If the patient experiences any adverse effects or withdrawal symptoms, consider slowing down the tapering schedule or seeking alternative treatments.