What is the recommended dose and frequency of Metoprolol (beta blocker)?

From the Guidelines

Metoprolol should be prescribed at a dose of 25 to 50 mg every 6 to 12 hours orally, then transitioned over the next 2 to 3 days to twice-daily dosing of metoprolol tartrate or to daily metoprolol succinate, with a target dose of 200 mg daily as tolerated. This recommendation is based on the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. The dosing should be individualized based on patient response and tolerance.

Key Considerations

• The initial dose of metoprolol can be given intravenously at 5 mg every 5 minutes as tolerated up to 3 doses for patients with refractory hypertension or ongoing ischemia without contraindication 1.
• For patients with heart failure, the starting dose is usually lower, at 12.5-25 mg twice daily, and should be gradually increased to a target dose of 200 mg daily 1.
• The extended-release formulation (metoprolol succinate) can be given once daily, typically 50-400 mg depending on the condition.
• Metoprolol works by blocking beta-1 adrenergic receptors primarily in the heart, reducing heart rate, contractility, and blood pressure.
• It should be taken consistently, preferably with meals to enhance absorption, and never stopped abruptly as this can trigger rebound hypertension or angina.
• Dose adjustments may be necessary for elderly patients or those with liver impairment.

Contraindications and Precautions

• Metoprolol should be avoided in patients with signs of heart failure, low output state, increased risk of cardiogenic shock, prolonged first-degree or high-grade AV block, or reactive airways disease 1.
• Patients with significant chronic obstructive pulmonary disease should be given metoprolol cautiously, with initial low doses of a beta-1–selective agent 1.

Monitoring and Maintenance

• Monitoring during intravenous beta-blocker therapy should include frequent checks of heart rate and blood pressure and continuous ECG monitoring, as well as auscultation for rales and bronchospasm 1.
• The target resting heart rate is 50 to 60 beats per minute unless a limiting side effect is reached.
• Selection of the oral agent should include the clinician's familiarity with the agent.

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 Start patients who appear not to tolerate the full intravenous on metoprolol tartrate tablets either 25 mg or 50 mg every 6 hours (depending on the degree of intolerance) 15 minutes after the last intravenous dose or as soon as their clinical condition allows.

The recommended dose and frequency of Metoprolol (beta blocker) is:

• Initial dose: 3 bolus injections of 5 mg of metoprolol tartrate injection each, given at approximately 2-minute intervals
• Oral dose after intravenous administration: 50 mg every 6 hours for 48 hours, then
• Maintenance dose: 100 mg orally twice daily 2
• Alternative dose for intolerance: 25 mg or 50 mg every 6 hours, depending on the degree of intolerance 2

From the Research

Recommended Dose and Frequency of Metoprolol

The recommended dose and frequency of Metoprolol can vary depending on the specific condition being treated.

• For patients with acute myocardial infarction, the target daily dose of metoprolol used in randomized clinical trials is 200 mg 3.
• In a study on the hemodynamic effects of metoprolol in acute myocardial infarction, patients were given 15 mg intravenously and 50 mg 4 times a day orally 4.
• For hypertension, metoprolol can be given twice daily, with some evidence suggesting that once daily administration may be possible 5.
• A study on atenolol and metoprolol once daily in hypertension found that metoprolol 100 mg/day and 200 mg/day in a sustained-release formulation were effective in controlling blood pressure 6.
• For heart failure, the recommended initiating dose of metoprolol succinate is 12.5 mg, which can be increased gradually over weeks to a target dose that achieves adequate bradycardia 7.

Key Considerations

• The dose of metoprolol may need to be adjusted based on the patient's response and tolerance to the medication.
• The medication should be started at a low dose and gradually increased to minimize side effects.
• Metoprolol can be given in various formulations, including standard and sustained-release formulations.