What is the recommended starting dosage of a beta blocker, such as Metoprolol (Metoprolol), for an older patient with hypertension (elevated blood pressure), palpitations, and normal heart rate, who is currently taking Valsartan (Diovan) 320 mg daily and has experienced adverse reactions to Hydrochlorothiazide (HCTZ) and Amlodipine?

Beta Blocker Starting Dosage for Older Patient with Hypertension and Palpitations

For an older patient with hypertension (150s/90s), palpitations, normal heart rate, and anxiety who has experienced adverse reactions to HCTZ (redness) and amlodipine (swelling), the recommended starting dosage of metoprolol is 25-50 mg twice daily of immediate-release metoprolol tartrate or 50 mg once daily of extended-release metoprolol succinate.

Rationale for Adding a Beta Blocker

Adding a beta blocker to the current regimen of valsartan 320 mg is appropriate for this patient for several reasons:

• The patient's blood pressure remains elevated (150s/90s) despite maximum dose of valsartan
• The patient experiences palpitations that could benefit from beta blockade
• Beta blockers may provide additional benefit for anxiety symptoms
• Previous adverse reactions to HCTZ and amlodipine limit other first-line options

Dosing Recommendations

Initial Dosing:

• Metoprolol tartrate (immediate-release): Start with 25-50 mg twice daily
• Metoprolol succinate (extended-release): Start with 50 mg once daily

Titration Strategy:

• Reassess blood pressure and symptoms after 2-4 weeks 1
• If needed and tolerated, increase dose gradually
• Maximum doses: 100 mg twice daily for tartrate or 200 mg daily for succinate

Considerations for Older Patients

When prescribing beta blockers to older patients, several factors require attention:

• Start low, go slow: Begin with lower doses in older patients to minimize adverse effects
• Monitor closely: Watch for bradycardia, hypotension, fatigue, and bronchospasm
• Cognitive effects: Be aware of potential for confusion or depression in some older patients
• Drug interactions: Consider potential interactions with other medications the patient may be taking

Treatment Algorithm

1. First step: Continue valsartan 320 mg daily and add metoprolol at starting dose
2. Monitor: Check BP, heart rate, and symptoms within 2-4 weeks of initiation
3. Adjust: Titrate metoprolol dose based on response and tolerability
4. Target: Aim to reduce BP by at least 20/10 mmHg, ideally to <140/90 mmHg 2

Alternative Approaches

If metoprolol is not tolerated or contraindicated:

• Consider other beta blockers (bisoprolol, starting at 2.5-5 mg daily)
• Consider adding spironolactone (starting at 25 mg daily) if no contraindications 2, 1

Monitoring and Follow-up

• Check BP and heart rate within 2-4 weeks after starting metoprolol
• Monitor for side effects: fatigue, dizziness, bradycardia, bronchospasm
• Assess improvement in palpitations and anxiety symptoms
• Consider home BP monitoring to evaluate treatment efficacy

Cautions and Pitfalls

• Avoid abrupt discontinuation: Beta blockers should be tapered gradually to prevent rebound hypertension
• Bradycardia risk: Monitor heart rate, especially in older patients
• Masking hypoglycemia: Use with caution if patient has diabetes
• Bronchospasm: Use cautiously in patients with respiratory conditions
• Avoid combining beta-blockers and thiazides due to increased risk of new-onset diabetes 1

Recent evidence suggests that a combination of amlodipine plus bisoprolol (a beta blocker) may be associated with a lower risk of hemorrhagic stroke compared to amlodipine plus valsartan, with similar outcomes for all-cause mortality and cardiovascular events 3. However, given this patient's previous adverse reaction to amlodipine (swelling), this specific combination is not recommended.