Metoprolol to Carvedilol Conversion Protocol
When converting a patient from metoprolol to carvedilol, start carvedilol at approximately half the equivalent total daily dose of metoprolol, then titrate upward at 2-week intervals to target dose or maximum tolerated dose. 1
Conversion Equivalence Table
| Metoprolol Succinate Dose | Initial Carvedilol Dose |
|---|---|
| 12.5-25 mg daily | 3.125 mg twice daily |
| 50 mg daily | 6.25 mg twice daily |
| 100 mg daily | 12.5 mg twice daily |
| 200 mg daily | 25 mg twice daily |
Conversion Process
- Discontinue metoprolol and immediately start carvedilol at the appropriate equivalent dose based on the table above
- Initial monitoring: Check heart rate, blood pressure, and clinical status within 24 hours after switching, especially in hospitalized patients 2
- Dose titration: Double the dose at 2-week intervals if tolerated 2
- Target dose: Aim for carvedilol 25-50 mg twice daily depending on patient weight (25 mg BID for patients <85 kg, 50 mg BID for patients >85 kg) 2
Monitoring Parameters
- Heart rate (target: 50-60 beats per minute)
- Blood pressure
- Signs of congestion (jugular venous pressure, peripheral edema)
- Body weight (daily monitoring recommended for patients)
- Clinical symptoms (especially worsening heart failure)
- Blood chemistry at 12 weeks after initiation and 12 weeks after final dose titration 2
Special Considerations
- Heart failure patients: Conversion should be done cautiously, preferably when patients are stable. Evidence suggests carvedilol may provide mortality benefit over metoprolol in heart failure patients 3
- Hospitalized patients: For recently decompensated patients, conversion can be initiated pre-discharge with careful monitoring 2
- Severe heart failure (NYHA class IV): Seek specialist advice before conversion 2
Managing Adverse Effects During Conversion
If worsening symptoms occur during conversion:
- For increasing congestion: Double the dose of diuretic and/or temporarily halve the dose of carvedilol
- For marked fatigue or bradycardia: Reduce the carvedilol dose by half
- For serious deterioration: Consider halving the dose or temporarily stopping carvedilol 2
Important Cautions
- Avoid abrupt discontinuation of either beta-blocker
- Remember that carvedilol is non-selective (blocks β1, β2, and α1 receptors) while metoprolol is β1-selective, which may cause different side effect profiles 4
- Patients switching from metoprolol to carvedilol generally experience fewer adverse events than those switching from carvedilol to metoprolol 5
- Carvedilol may cause more dizziness or hypotension than metoprolol due to its alpha-blocking properties 6
This conversion protocol prioritizes patient safety while ensuring effective beta-blockade is maintained throughout the transition process.