What is the recommended daily dose of metoprolol (metoprolol succinate)?

Maximum Daily Dose of Metoprolol Succinate

The maximum recommended daily dose of metoprolol succinate is 200 mg once daily. 1

Dosing Guidelines for Metoprolol Succinate

General Dosing

• Metoprolol succinate is available as an extended-release (ER) formulation that allows for once-daily dosing 1
• The typical starting dose is 25-50 mg once daily, with gradual titration to the target dose 1
• The controlled-release/extended-release formulation provides relatively constant plasma concentrations over approximately 20 hours 2
• A 100 mg metoprolol succinate tablet is considered to have equivalent activity to 100 mg of metoprolol tartrate 2

Condition-Specific Dosing

Heart Failure

• For heart failure patients, the recommended initial dose is 12.5-25 mg once daily 1
• Dose may be doubled every 1-2 weeks if the preceding dose was well tolerated 1
• Target dose in heart failure is 200 mg once daily 1
• In clinical trials, the mean dose achieved was 159 mg daily 1
• Titration period typically takes weeks to months 1

Hypertension

• For hypertension, the usual dose range is 50-400 mg once daily 1
• Metoprolol succinate can be used as monotherapy or in combination with other antihypertensives such as diuretics 1, 2

Post-Myocardial Infarction

• After initial IV therapy in acute MI (if used), oral metoprolol is typically started at 50 mg every 6 hours for 48 hours 1, 3
• Maintenance dose after MI is 100 mg twice daily 1, 3

Special Populations

Elderly Patients

• Lower initial doses should be considered in elderly patients due to potentially decreased hepatic, renal, or cardiac function 3
• Despite this caution, studies show metoprolol is generally well-tolerated in elderly hypertensive patients 4

Hepatic Impairment

• Metoprolol blood levels may increase substantially in patients with hepatic impairment 3
• Lower initial doses with cautious gradual titration are recommended 3
• Elimination half-life can be prolonged up to 7-9 hours in patients with hepatic impairment 3

Renal Impairment

• No dose adjustment is required in patients with renal impairment 3

Administration Considerations

• Metoprolol succinate tablets should not be crushed or chewed; they disintegrate into individual pellets that act as diffusion cells releasing the drug at a relatively constant rate 2
• The extended-release formulation allows for once-daily dosing, improving patient adherence 2, 5
• When switching from immediate-release to extended-release formulation, the same total daily dose can be used 3

Monitoring and Dose Adjustments

• During titration, monitor for evidence of heart failure symptoms, fluid retention, hypotension, and symptomatic bradycardia 1
• If worsening symptoms occur, consider increasing diuretics or ACE inhibitors before reducing beta-blocker dose 1
• For hypotension, first reduce the dose of vasodilators; reduce beta-blocker dose if necessary 1
• For bradycardia, reduce or discontinue drugs that may lower heart rate; reduce beta-blocker dose if necessary 1

Contraindications

• Avoid initiating in patients with signs of heart failure, low output state, or increased risk for cardiogenic shock 1
• Do not use in patients with PR interval >0.24 seconds, second or third-degree heart block, active asthma, or reactive airways disease 1
• Use cautiously in patients with bronchospastic airway disease requiring a beta-blocker 1

Remember that metoprolol succinate is a long-acting formulation designed to maintain therapeutic levels over 24 hours, allowing for once-daily dosing with a maximum recommended dose of 200 mg daily.