What is the recommended starting dose of metoprolol (beta blocker) for hypertension and heart failure?

Recommended Starting Dose of Metoprolol for Hypertension and Heart Failure

For heart failure, the recommended starting dose of metoprolol is 12.5-25 mg once daily for metoprolol succinate (CR/XL), with gradual titration every 2 weeks to a target dose of 200 mg once daily; for hypertension, the starting dose is typically 25-100 mg daily. 1

Heart Failure Dosing

Initial Dosing

• Metoprolol succinate (CR/XL):

  • Starting dose: 12.5-25 mg once daily
  • Target dose: 200 mg once daily
  • Titration: Increase dose every 2 weeks as tolerated 1, 2

• Metoprolol tartrate:

  • Starting dose: 12.5 mg twice daily
  • Target dose: 100-150 mg daily (divided doses)
  • Titration: Increase gradually over 6-8 weeks 3, 4

Patient Selection and Precautions

• Initiate only after stabilization in patients with recent heart failure decompensation
• Avoid initiation if:
  • Heart rate <50 bpm
  • Systolic BP <90 mmHg
  • Cardiogenic shock
  • Decompensated heart failure requiring IV inotropic therapy
  • Severe asthma or bronchospasm 1

Monitoring During Titration

• Monitor heart rate and blood pressure at each dose increase
• Assess for signs of worsening heart failure, symptomatic bradycardia, or hypotension
• If adverse effects occur, temporarily reduce dose rather than discontinuing completely 1

Hypertension Dosing

• Metoprolol succinate (CR/XL):

  • Starting dose: 25-100 mg once daily
  • Maximum dose: 400 mg daily
  • Typical effective dose: 100-200 mg once daily 5

• Metoprolol tartrate:

  • Starting dose: 50 mg twice daily
  • Titration: Increase as needed based on blood pressure response
  • Usual maintenance dose: 100-200 mg daily in divided doses 5

Clinical Evidence Supporting Dosing

The MERIT-HF trial demonstrated that metoprolol CR/XL at a starting dose of 12.5-25 mg once daily, gradually increased to a target dose of 200 mg once daily, reduced all-cause mortality by 34% in heart failure patients 2, 6. This mortality benefit included a 41% decrease in sudden death and a 49% decrease in death from progressive heart failure 3.

For hypertension, once-daily dosing with metoprolol CR/XL 100-200 mg has been shown to be as effective as twice-daily dosing with conventional metoprolol tablets 5.

Important Considerations

• Slow titration is crucial: The "start low, go slow" approach minimizes adverse effects, particularly in heart failure patients 1

• Target doses matter: Higher doses provide greater benefits than lower doses, with little evidence that subtarget doses yield comparable survival benefits 3

• Common pitfalls:

  • Many physicians use doses appropriate for hypertension (25-100 mg daily) when treating heart failure, which are inadequate for mortality reduction 3
  • Dose reductions are often made permanent in clinical practice, whereas in clinical trials, 40% of patients who required temporary dose reductions were subsequently restored to target doses 3
  • Asymptomatic hypotension is often unnecessarily used as a reason to avoid uptitration 3

• Combination therapy: Beta-blockers like metoprolol can be used effectively in combination with ACE inhibitors/ARBs, diuretics, and SGLT2 inhibitors in heart failure management 1

Remember that achieving target doses is associated with improved survival outcomes in heart failure patients, and every effort should be made to reach these doses through careful titration while managing potential adverse effects.