Can metoprolol (beta blocker) be used in a patient with severe coronary artery disease, end-stage renal disease (ESRD) requiring dialysis, and residual renal function, who produces urine and responds to diuretics, for managing angina and hypertension?

Metoprolol Use in ESRD Patients with Residual Renal Function

Metoprolol can be safely used in patients with end-stage renal disease requiring dialysis who have residual renal function, and is actually recommended as a preferred beta-blocker for managing angina and hypertension in patients with severe coronary artery disease. 1, 2

Benefits of Metoprolol in ESRD Patients with CAD

• Beta-blockers, including metoprolol, are recommended as part of the medical management of chronic coronary artery disease in dialysis patients, following the same guidelines as for the general population 1
• Metoprolol is a cardioselective beta-blocker that has been shown to be effective in managing angina and hypertension, with minimal dose adjustments needed for patients with renal failure 3
• The American Heart Association recommends beta-blockers as first-line therapy for patients with coronary artery disease, with metoprolol being one of the preferred agents due to its cardioselectivity 1, 2

Pharmacokinetics in ESRD

• The systemic availability and half-life of metoprolol in patients with renal failure do not differ to a clinically significant degree from those in normal subjects 3
• Consequently, no significant dose reduction is usually needed in patients with chronic renal failure, including those on dialysis 3, 1
• Metoprolol is primarily eliminated by hepatic metabolism, with only about 10% of an intravenous dose excreted unchanged in the urine in most subjects 3

Dosing Considerations

• For patients with ESRD who produce urine and respond to diuretics, loop diuretics may be helpful to increase urine output in those with substantial residual renal function 1
• Modification of dosing regimens should be considered so that cardiovascular medications do not adversely impact the delivery of dialysis and ultrafiltration 1
• Nocturnal dosing of medications should be considered to minimize hemodynamic fluctuations during dialysis 1

Special Considerations for ESRD Patients

• Cardiovascular disease is a major concern for ESRD patients on hemodialysis, with higher mortality rates compared to the general population 4, 5
• ESRD patients often have more severe coronary lesions characterized by increased media thickness and marked calcification 4
• Clinical manifestations of cardiovascular disease are highly prevalent at the start of ESRD therapy, with 14% having coronary artery disease and 19% having angina pectoris 5

Precautions and Monitoring

• Monitor for signs of heart failure, as beta-blockers can cause depression of myocardial contractility 3
• Do not abruptly discontinue metoprolol therapy in patients with coronary artery disease, as severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported 3
• When using metoprolol in combination with other antihypertensives, monitor for hypotension, especially at the end of hemodialysis sessions 1

Comprehensive Treatment Approach

• The medical management of chronic CAD in dialysis patients should include acetylsalicylic acid (ASA), beta-blockers (such as metoprolol), nitroglycerin, ACE inhibitors or ARBs, statins, and/or calcium channel blockers as indicated 1
• For patients with residual renal function who respond to diuretics, loop diuretics should be considered as part of the management strategy 1
• For optimal blood pressure control, a target of <140/90 mmHg is recommended, with consideration of <130/80 mmHg in some individuals with CAD 1

In conclusion, metoprolol is a safe and effective option for managing angina and hypertension in ESRD patients with residual renal function and severe coronary artery disease. Its primarily hepatic metabolism means minimal dose adjustments are needed, making it a preferred beta-blocker in this population.