What is the maximum recommended dosage of Metoprolol (beta-blocker) for treating hypertension and other indications?

Maximum Dosage of Metoprolol for Various Indications

The maximum recommended dosage of metoprolol tartrate is 200 mg daily for hypertension, while metoprolol succinate (extended-release) has a maximum daily dose of 400 mg. 1, 2, 3

Formulation-Specific Maximum Dosages

• Metoprolol tartrate (immediate-release):

  • Hypertension: Maximum 200 mg daily, typically divided into two doses 1, 2
  • Usual dose range: 100-200 mg daily 1
  • Initial dose: 25-50 mg twice daily, with gradual titration 2

• Metoprolol succinate (extended-release):

  • Maximum dose: 400 mg once daily 2
  • Usual dose range: 50-200 mg once daily 1
  • Mean dose achieved in heart failure trials: 159 mg daily 1

Indication-Specific Dosing

• Hypertension:

  • Metoprolol tartrate: 100-450 mg daily has been shown effective in controlled studies 3
  • Most patients with mild to moderate hypertension can be controlled with once-daily dosing of extended-release formulation 4

• Heart Failure:

  • Target dose: 200 mg once daily of metoprolol succinate 1
  • Initial dose: 12.5-25 mg once daily with gradual titration at 2-week intervals 5
  • Mean dose achieved in MERIT-HF trial: 159 mg daily 1

• Myocardial Infarction:

  • Initial treatment: 50 mg every 6 hours for 48 hours following IV administration 3
  • Maintenance dose: 100 mg twice daily 3

Special Populations and Considerations

• Hepatic impairment: Lower maximum doses are recommended due to decreased metabolism and prolonged elimination half-life (up to 7.2 hours) 3

• Elderly patients: Lower initial doses are recommended due to potential decreased hepatic, renal, or cardiac function 3

• Poor CYP2D6 metabolizers (approximately 8% of Caucasians): May require lower maximum doses due to higher plasma concentrations and longer half-life (7-9 hours) 3

• Contraindications for metoprolol use include:

  • Signs of heart failure
  • Low output state
  • Increased risk for cardiogenic shock
  • PR interval >0.24 seconds
  • Second or third-degree heart block
  • Active asthma or reactive airways disease 2

Dose-Response Considerations

• Studies suggest a relatively horizontal dose-response curve at doses above 200 mg/day, indicating limited additional benefit with higher doses 6

• When initiating therapy, starting with low doses and gradually titrating upward is recommended to minimize adverse effects 2, 5

• For patients not responding to metoprolol monotherapy, addition of a thiazide diuretic may provide better blood pressure control than further increasing metoprolol dose 4

Administration Guidelines

• Avoid abrupt cessation of therapy to prevent rebound hypertension or worsening of angina 2

• Monitor blood pressure, heart rate, and signs of worsening heart failure during dose titration 2

• Target resting heart rate of 50-60 beats per minute unless limiting side effects occur 2