What is the maximum recommended dose of metoprolol (metoprolol tartrate) for hypertension and heart failure?

Maximum Recommended Dose of Metoprolol Tartrate

The maximum recommended dose of metoprolol tartrate is 450 mg daily for hypertension and 200 mg daily for heart failure, with dosing individualized based on clinical response and tolerability. 1, 2

Dosing for Hypertension

• Initial oral dose typically starts at 25-50 mg twice daily, with gradual titration based on blood pressure response 2
• Dose can be increased at 1-2 week intervals to achieve blood pressure control 1
• Maximum daily dose for hypertension is 450 mg, though most patients respond to 100-400 mg daily 1
• For sustained control, total daily doses are often divided into twice-daily administration 1

Dosing for Heart Failure

• Initial dose should be low: 12.5-25 mg once or twice daily, with careful titration to avoid decompensation 2
• Dose should be doubled every 1-2 weeks if the preceding dose was well tolerated 2
• Target dose is 200 mg daily (as documented in MERIT-HF trial) 2, 3
• For metoprolol tartrate specifically, dosing is typically divided (e.g., 25-50 mg twice daily), whereas metoprolol succinate CR/XL is given once daily 2

Important Considerations for Dosing

• Careful monitoring is essential during uptitration, especially for signs of worsening heart failure, hypotension, or bradycardia 2
• Higher doses provide greater mortality benefit in heart failure patients; medium-range doses may not provide equivalent survival benefits 2
• In acute settings (e.g., arrhythmias), IV metoprolol tartrate can be given as 5 mg over 1-2 minutes, repeated as required every 5 minutes to a maximum dose of 15 mg 2
• Patients with hepatic impairment may require lower doses due to prolonged elimination half-life (up to 7.2 hours) 1

Contraindications and Cautions

• Avoid in patients with signs of heart failure decompensation, low output state, or increased risk for cardiogenic shock 2
• Use with caution in patients with PR interval >0.24 seconds, second or third-degree heart block 2
• Contraindicated in patients with active asthma or reactive airways disease 2
• Risk factors for cardiogenic shock include age >70 years, systolic BP <120 mmHg, heart rate >110 bpm or <60 bpm 2

Special Populations

• Elderly patients may show slightly higher plasma concentrations but typically don't require dose adjustments unless other risk factors are present 1
• No significant dose adjustment needed for patients with chronic renal failure 1
• Poor CYP2D6 metabolizers (approximately 8% of Caucasians) may have 7-9 hour half-life versus 3-4 hours in normal metabolizers, potentially requiring lower doses 1

Remember that the maximum tolerated dose may be lower than the maximum recommended dose for individual patients. Careful monitoring during initiation and uptitration is essential to balance efficacy with safety, particularly in heart failure patients.