What is the dosing for Metoprolol (metoprolol) succinate?

From the Guidelines

Metoprolol succinate should be started at 12.5-25 mg once daily for heart failure and gradually increased to a target dose of 200 mg once daily as tolerated, based on the most recent and highest quality evidence from the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

Key Considerations

• The initial dose for hypertension and post-myocardial infarction can be 25-50 mg once daily, with gradual titration based on patient response.
• The medication should be taken once daily, preferably in the morning, with or without food, and tablets should be swallowed whole without crushing or chewing.
• Dose adjustments may be needed for elderly patients or those with hepatic impairment.

Mechanism of Action and Side Effects

• Metoprolol succinate works by blocking beta-1 adrenergic receptors, reducing heart rate and blood pressure while decreasing cardiac workload.
• Patients should be monitored for potential side effects including bradycardia, hypotension, fatigue, and bronchospasm, particularly during initial therapy and dose adjustments.

Clinical Trials and Guidelines

• The MERIT-HF trial demonstrated a significant decrease in all-cause mortality, cardiovascular mortality, sudden death, and death caused by progressive heart failure with metoprolol CR/XL treatment 2.
• The 2022 AHA/ACC/HFSA guideline recommends metoprolol succinate as a treatment option for heart failure with reduced ejection fraction, with a target dose of 200 mg once daily 1.
• Other guidelines, such as the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, also recommend metoprolol succinate as a treatment option for post-myocardial infarction patients 3.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital. Such treatment should be initiated in a coronary care or similar unit immediately after the patient’s hemodynamic condition has stabilized Begin treatment in this early phase with the intravenous administration of three bolus injections of 5 mg of metoprolol tartrate injection each; give the injections at approximately 2-minute intervals. During the intravenous administration of metoprolol tartrate injection, monitor blood pressure, heart rate, and electrocardiogram In patients who tolerate the full intravenous dose (15 mg), initiate metoprolol tartrate tablets, 50 mg every 6 hours, 15 minutes after the last intravenous dose and continued for 48 hours. Thereafter, the maintenance dosage is 100 mg orally twice daily

The FDA drug label does not answer the question about the dosing for Metoprolol (metoprolol) succinate because it only provides information about metoprolol tartrate dosing 4.

From the Research

Dosing for Metoprolol Succinate

• The dosing for metoprolol succinate is typically initiated at a low dosage of 12.5 to 25 mg once daily and gradually increased at 2-weekly intervals until the target dosage (200 mg once daily) or maximal tolerated dosage has been attained 5.
• The initiating dose should be very low, at 12.5 mg metoprolol succinate, and increased gradually over weeks 6.
• Treatment with metoprolol CR/XL was associated with a 34% reduction in relative risk of all-cause mortality in patients with chronic heart failure due to ischaemic or dilated cardiomyopathy in the MERIT-HF trial 5.
• Metoprolol succinate is administered once daily, is well tolerated, and provides consistent beta(1)-blockade over the 24-hour dosing interval 7.
• The dose of metoprolol succinate can be titrated upward by doubling the dose every 2 weeks until reaching a maximum tolerated dose or a goal dose of 200 mg/day 8.

Key Considerations

• The drug is well tolerated when treatment is initiated in low dosages and gradually increased at intervals of 1 to 2 weeks 5.
• Metoprolol succinate is effective in patients with stable mild to moderate (NYHA functional class II or III) chronic heart failure due to left ventricular systolic dysfunction, and the drug is effective in patients with ischaemic or dilated cardiomyopathy 5, 6.
• Although limited data indicate that metoprolol CR/XL is effective in patients with severe (NYHA functional class IV) chronic heart failure, more data are needed to confirm these findings 5.