What is the maximum recommended dose of metoprolol (beta-blocker)?

Maximum Recommended Dose of Metoprolol

The maximum recommended dose of metoprolol is 200 mg daily for metoprolol succinate (extended-release) and 200 mg daily (100 mg twice daily) for metoprolol tartrate. 1, 2

Dosing by Formulation

Metoprolol Tartrate (Immediate-Release)

• Maximum dose: 100 mg twice daily (200 mg total daily dose)
• Usual dosing range: 100-200 mg daily in divided doses
• Administration frequency: Twice daily dosing
• Indications: Hypertension, angina pectoris, acute myocardial infarction

Metoprolol Succinate (Extended-Release)

• Maximum dose: 200 mg once daily
• Usual dosing range: 50-200 mg daily
• Administration frequency: Once daily dosing
• Indications: Hypertension, heart failure, angina pectoris

Clinical Considerations

Heart Failure

• For heart failure patients, metoprolol succinate is the preferred formulation with a target dose of 200 mg once daily 2
• Initiate at low doses (12.5-25 mg once daily) and gradually titrate upward at 2-week intervals to the target dose or maximum tolerated dose 2, 3
• The MERIT-HF trial demonstrated significant mortality reduction with metoprolol CR/XL at a mean dose of 192 mg daily in patients who reached >100 mg daily 4

Hypertension

• For hypertension management, both formulations are effective with the maximum recommended doses as stated above 1
• The extended-release formulation provides more consistent 24-hour blood pressure control 5

Sex-Related Differences

• Women may require lower doses of metoprolol than men due to higher drug exposure
• Research suggests women may need approximately 50% dose reduction compared to men for equivalent effect 1
• Women experience 50-80% higher exposure to metoprolol and greater reduction in heart rate and blood pressure at equivalent doses 1

Dosing in Special Populations

Elderly Patients

• Elderly patients, particularly women, may require lower doses
• For elderly women, doses of 15 mg may produce effects equivalent to 50 mg in young men 1
• For elderly men, doses of 25 mg may produce effects equivalent to 50 mg in young men 1

Renal/Hepatic Impairment

• Dose adjustments may be necessary in patients with significant hepatic dysfunction as metoprolol is primarily metabolized by the liver
• No specific dose adjustment is required for renal impairment

Safety Considerations

• Avoid abrupt discontinuation of metoprolol as this can precipitate angina, myocardial infarction, or ventricular arrhythmias 1
• Beta blockers are contraindicated in patients with:
  • Marked first-degree AV block
  • Second or third-degree AV block without pacemaker
  • Severe bradycardia
  • Cardiogenic shock
  • Decompensated heart failure
  • Severe bronchospastic disease 2

Pharmacokinetic Considerations

• Extended-release metoprolol succinate provides more consistent plasma concentrations over 24 hours compared to immediate-release formulation 5
• The extended-release formulation delivers metoprolol at a near-constant rate for approximately 20 hours, independent of food intake and gastrointestinal pH 5

In summary, while the maximum recommended dose of metoprolol is 200 mg daily for both formulations, the appropriate dose should be determined based on the specific formulation, indication, patient characteristics (particularly sex and age), and clinical response.