Can metoprolol (beta blocker) and lisinopril (angiotensin-converting enzyme inhibitor) be used together?

Metoprolol and Lisinopril Combination Therapy

Metoprolol (beta-blocker) and lisinopril (ACE inhibitor) can be safely and effectively used together, especially when there are specific indications for beta-blocker use such as heart failure with reduced ejection fraction, post-myocardial infarction, or for heart rate control. 1

Efficacy and Safety of the Combination

• Beta-blockers (including metoprolol) can be effectively combined with any of the other major blood pressure-lowering drug classes when there are compelling indications for their use 1
• The combination of beta-blockers with ACE inhibitors is particularly beneficial in patients with specific cardiovascular conditions such as heart failure with reduced ejection fraction (HFrEF) 1
• Metoprolol succinate and bisoprolol are preferred beta-blockers in patients with HFrEF 1
• Both metoprolol and lisinopril have demonstrated effective blood pressure reduction when used individually 2, 3

Recommended Combinations for Hypertension

• The 2024 ESC guidelines recommend specific two-drug combinations for hypertension management, with preferred combinations being a renin-angiotensin system (RAS) blocker (such as an ACE inhibitor like lisinopril) with either a dihydropyridine calcium channel blocker or a diuretic 1
• While beta-blockers are not first-line agents for hypertension unless specific indications exist, they can be added to the treatment regimen when needed 1
• If blood pressure is not controlled with a three-drug combination (typically a RAS blocker, calcium channel blocker, and diuretic), adding a beta-blocker can be considered 1

Dosing Considerations

• Metoprolol tartrate is typically dosed at 100-200 mg daily in two divided doses, while metoprolol succinate is dosed at 50-200 mg once daily 1
• Lisinopril is typically dosed at 20-40 mg once daily for hypertension 1
• When combining these medications, it's important to monitor for potential additive effects on blood pressure and heart rate 4

Special Populations and Considerations

• The combination is particularly beneficial in patients with:

  • Heart failure with reduced ejection fraction 1
  • Post-myocardial infarction 1
  • Angina 1
  • Need for heart rate control 1

• Caution should be exercised in patients with:

  • Symptomatic orthostatic hypotension 1
  • Moderate-to-severe frailty 1
  • Advanced age (≥85 years) 1

Important Precautions

• Avoid abrupt cessation of beta-blockers like metoprolol 1
• Monitor for potential additive hypotensive effects when using both medications together 4
• While the combination of an ACE inhibitor and beta-blocker is acceptable, combining two RAS blockers (such as an ACE inhibitor with an ARB) is not recommended 1

Clinical Pearls

• Fixed-dose single-pill combinations are recommended when possible to improve adherence 1
• Medications should be taken at the most convenient time of day for the patient to establish a habitual pattern and improve adherence 1
• For patients with heart failure, both metoprolol and lisinopril are included in the standard guideline-directed medical therapy 1

In conclusion, the combination of metoprolol and lisinopril is safe and effective, particularly in patients with specific cardiovascular conditions that benefit from beta-blocker therapy alongside ACE inhibition. This combination should be considered part of a comprehensive approach to managing hypertension and cardiovascular disease in appropriate patients.