What is the recommended tapering schedule for metoprolol (beta-blocker)?

Metoprolol Tapering Protocol

Metoprolol should be gradually tapered over 1-2 weeks when discontinuing therapy, especially in patients with coronary artery disease, to prevent rebound hypertension, tachycardia, or exacerbation of angina. 1

Tapering Rationale and Importance

• Abrupt discontinuation of metoprolol can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias in patients with coronary artery disease 1
• Even in patients treated only for hypertension, gradual tapering is recommended as coronary artery disease may be unrecognized 1
• Tapering helps prevent enhanced beta-adrenergic sensitivity that can occur after withdrawal 2

Recommended Tapering Schedule

• For metoprolol tartrate (immediate release):

  • Reduce the dose by approximately 25-50% every 1-2 weeks 3
  • Consider transitioning from twice daily dosing to a prolonged small dose (approximately 25% of original dose) for the final 2 weeks before complete withdrawal 2

• For metoprolol succinate (extended release):

  • Reduce the dose gradually over 1-2 weeks, decreasing by 25-50% at each step 4
  • For patients on higher doses (e.g., 200mg daily), consider an intermediate step at 100mg before further reduction 5

Monitoring During Tapering

• Monitor for signs of:

  • Worsening heart failure symptoms 3
  • Rebound hypertension 1
  • Tachycardia 1
  • Exacerbation of angina 1
  • Increased blood pressure 6

• Check heart rate and blood pressure at each dose reduction 4

• If symptoms worsen during tapering, consider temporarily returning to the previous dose before attempting a more gradual taper 3

Special Considerations

• For patients with heart failure:

  • More cautious tapering may be required with smaller incremental reductions 3
  • If worsening of heart failure occurs during tapering, consider increasing diuretics or ACE inhibitors temporarily 3
  • Always consider reintroduction and/or uptitration of the beta-blocker when the patient becomes stable 3

• For patients with coronary artery disease:

  • If angina markedly worsens or acute coronary insufficiency develops during tapering, metoprolol should be reinstated promptly 1
  • More gradual tapering (over 2+ weeks) may be necessary 1

Potential Withdrawal Effects to Monitor

• Rebound tachycardia 6
• Blood pressure elevation 6
• Headache, palpitations, and tremor 6
• Enhanced beta-adrenergic sensitivity 2

Common Pitfalls to Avoid

• Tapering too quickly, especially in patients with known coronary artery disease 1
• Failing to monitor heart rate and blood pressure during the tapering process 4
• Not having a plan to reinstate therapy if withdrawal symptoms occur 1
• Completely stopping the medication without a final period on a small maintenance dose 2