What to do with a patient with hypertension (elevated blood pressure) on metoprolol (beta blocker) 25mg twice daily (BD) before a colonoscopy?

Management of Hypertension Before Colonoscopy

For a patient with elevated blood pressure (188 mmHg) on metoprolol 25mg twice daily before colonoscopy, continue the metoprolol dose and proceed with the colonoscopy as scheduled, as this is not a hypertensive emergency requiring intervention.

Assessment of Blood Pressure Status

When evaluating a patient with elevated blood pressure before a colonoscopy:

• BP of 188 mmHg without symptoms of end-organ damage does not constitute a hypertensive emergency
• The patient is already on an appropriate antihypertensive medication (metoprolol 25mg BD)
• The patient has already received their scheduled dose of metoprolol

Management Algorithm

1. Continue scheduled metoprolol dose

   • Metoprolol is an appropriate beta-blocker for hypertension management 1
   • The current dose (25mg twice daily) is within the recommended initial dosing range 1
   • Abrupt discontinuation of beta-blockers should be avoided

2. Proceed with colonoscopy as scheduled

   • Enhanced Recovery After Surgery (ERAS) guidelines recommend continuing essential cardiovascular medications perioperatively 1
   • There is no evidence supporting cancellation of colonoscopy for non-emergency BP elevations

3. Post-procedure follow-up

   • Schedule follow-up to reassess BP control
   • Consider dose adjustment if BP remains elevated (maximum metoprolol tartrate dose is 200mg BID) 1

Medication Considerations

• Metoprolol effectiveness: Metoprolol tartrate 25mg BID is an appropriate starting dose for hypertension 1
• Dosing schedule: Both once-daily and twice-daily metoprolol regimens can be effective for BP control 2, 3
• Potential adjustments: If BP remains uncontrolled, dosage can be increased up to 200mg BID 1

Important Caveats

• Monitor for symptoms: Watch for signs of hypertensive emergency (severe headache, visual changes, chest pain, neurological deficits)
• Avoid rapid BP reduction: Aggressive acute lowering of BP can lead to organ hypoperfusion 1
• Beta-blocker continuation: Abrupt discontinuation of beta-blockers can lead to rebound hypertension and tachycardia

Long-term Management Considerations

For ongoing management after the procedure:

• Consider uptitration of metoprolol if BP remains consistently elevated
• Target BP should be <130/80 mmHg according to current guidelines 1
• Consider combination therapy if monotherapy with beta-blocker is insufficient

This approach balances the need to maintain BP control while avoiding unnecessary procedure delays when the patient is already on appropriate antihypertensive therapy.