What is the maximum daily dose of metoprolol (beta-blocker) for conditions like hypertension or heart failure?

Maximum Daily Dose of Metoprolol

The maximum daily dose of metoprolol is 200 mg for hypertension and 200 mg for heart failure, with specific formulations and dosing schedules depending on the condition being treated.

Metoprolol Dosing for Hypertension

According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guidelines for hypertension management 1, metoprolol is available in two salt forms with different dosing recommendations:

• Metoprolol tartrate: 100-200 mg daily, divided into 2 doses
• Metoprolol succinate (extended-release): 50-200 mg once daily

The FDA-approved labeling for metoprolol confirms these dosing parameters, noting that in controlled clinical studies, effective antihypertensive doses ranged from 100 to 450 mg daily 2.

Metoprolol Dosing for Heart Failure

For heart failure, the maximum recommended dose is also 200 mg daily:

• Metoprolol CR/XL (controlled-release/extended-release): Target dose of 200 mg once daily 3, 4

The MERIT-HF trial, which demonstrated a 34% reduction in all-cause mortality with metoprolol CR/XL, used a target dose of 200 mg once daily 3. This has become the established maximum daily dose for heart failure treatment.

Dosing Protocol and Titration

When initiating metoprolol therapy, especially in heart failure patients, a gradual titration schedule is crucial:

1. Starting dose:

   • For heart failure: 12.5-25 mg once daily (lower dose for NYHA class III-IV) 3
   • For hypertension: Usually start at 25-50 mg twice daily for immediate release 2

2. Titration:

   • Increase dose gradually at 2-week intervals if well tolerated 3
   • For heart failure, titrate over 6-8 weeks to reach target dose of 200 mg daily 4

3. Monitoring during titration:

   • Blood pressure
   • Heart rate
   • Signs of worsening heart failure
   • Symptoms of hypotension or bradycardia

Special Considerations

• Post-myocardial infarction: The recommended maintenance dose is 100 mg orally twice daily (200 mg total) for 48 hours after the initial IV loading doses 2

• Renal impairment: No dose adjustment required 2

• Hepatic impairment: Lower initial doses with cautious titration due to substantially increased blood levels 2

• Elderly patients: Start with lower doses due to potential decreased hepatic, renal, or cardiac function 2

• Poor CYP2D6 metabolizers: May have 7-9 hour half-life (vs. 3-4 hours in normal metabolizers), potentially requiring lower doses 2

Important Warnings

• Abrupt discontinuation should be avoided as it may precipitate angina, myocardial infarction, or ventricular arrhythmias 1

• For patients with severe heart failure, careful monitoring during initiation and dose titration is essential to avoid decompensation 1

• Contraindicated in patients with severe bradycardia, heart block greater than first degree, cardiogenic shock, or decompensated heart failure 1

Metoprolol's maximum daily dose of 200 mg applies to both hypertension and heart failure management, though the specific formulation (immediate-release vs. extended-release) and dosing schedule will differ based on the condition being treated and individual patient factors.