Maximum Dose of Metoprolol
The maximum daily dose of metoprolol varies by formulation: for immediate-release metoprolol tartrate, the maximum is 400 mg daily (200 mg twice daily); for extended-release metoprolol succinate, the maximum is 400 mg once daily. 1
Formulation-Specific Dosing
Metoprolol Tartrate (Immediate-Release)
- Initial oral dose: 25-50 mg twice daily 2
- Maximum daily dose: 400 mg (200 mg twice daily) 2
- For intravenous administration: 2.5-5.0 mg IV bolus over 2 minutes, can repeat up to 3 doses (maximum 15 mg total) 2, 1
Metoprolol Succinate (Extended-Release)
- Initial oral dose: 25-50 mg once daily 2
- Maximum daily dose: 400 mg once daily 2
- Extended-release formulation provides consistent beta1-blockade over 24 hours without marked peaks and troughs 3
Clinical Context and Dosing Considerations
Heart Failure
- Start at lower doses: 12.5-25 mg once daily of metoprolol succinate CR/XL 4
- Target dose: 200 mg once daily (MERIT-HF trial) 5
- Gradual up-titration: Increase at 2-week intervals to target or maximum tolerated dose 4
- Note: Some patients achieve similar heart rate reduction and mortality benefit at lower doses (mean 76 mg daily) compared to higher doses (mean 192 mg daily) 6
Acute Coronary Syndromes
- IV administration: 5 mg slow IV bolus over 2 minutes
- May repeat 5 mg at 5-minute intervals up to 15 mg total 1
- Transition to oral therapy: Begin 25 mg orally every 6 hours for 48 hours, then maintenance dose 1
Supraventricular Tachycardia
- IV administration: 2.5-5.0 mg IV bolus over 2 minutes
- Can repeat up to 3 doses (maximum 15 mg) 2
Important Precautions
Avoid or use with caution in patients with:
- AV block greater than first degree or SA node dysfunction
- Decompensated heart failure
- Hypotension or cardiogenic shock
- Reactive airway disease
- Severe renal dysfunction 2
Careful dose titration is essential to minimize adverse effects, particularly in:
- Elderly patients (>70 years)
- Patients with low systolic BP (<120 mmHg)
- Bradycardia (<60 bpm) or tachycardia (>110 bpm) 1
Monitoring Parameters
- Heart rate (target 50-60 bpm unless limiting side effects occur)
- Blood pressure
- Signs of heart failure exacerbation
- Respiratory status, especially in patients with history of reactive airway disease 1
Ethnic Considerations
Some evidence suggests that certain populations may require lower doses to achieve similar beta-blockade effects. A small study in Indian patients suggested that 50-100 mg daily might provide sufficient beta-blockade compared to the 200 mg used in European trials 7.