What is the initial dose of metoprolol (beta blocker) for a patient with new-onset hypertension and tachycardia?

Initial Dosing of Metoprolol for New-Onset Hypertension and Tachycardia

For a patient with new-onset hypertension and tachycardia, the recommended initial dose of metoprolol tartrate is 25 mg twice daily, with titration up to a maximum of 200 mg daily as tolerated. 1

Dosing Recommendations

• For metoprolol tartrate (immediate-release formulation):

  • Start with 25 mg twice daily 2, 1
  • Titrate gradually every 1-2 weeks based on blood pressure and heart rate response 1
  • Maximum daily dose: 200 mg 2

• For metoprolol succinate (extended-release formulation):

  • Start with 50 mg once daily 2, 1
  • Titrate gradually based on clinical response 1
  • Maximum daily dose: 400 mg 2

Monitoring Parameters

• Monitor blood pressure and heart rate at each follow-up visit 1
• Target resting heart rate of 50-60 beats per minute unless limiting side effects occur 1
• Assess for signs of worsening heart failure or bronchospasm, particularly during initiation 1
• For optimal blood pressure control, aim for a reduction of at least 20/10 mmHg, ideally to below 140/90 mmHg 1

Contraindications and Precautions

• Avoid in patients with:

  • Asthma or reactive airway disease 2, 1
  • Second or third-degree heart block or sick sinus syndrome without a pacemaker 2, 1
  • Decompensated heart failure 2, 1
  • Severe bradycardia (heart rate <50 bpm) 2
  • Cardiogenic shock 1

• Use with caution in patients with:

  • Diabetes (may mask hypoglycemic symptoms) 2
  • Peripheral vascular disease 2
  • Renal dysfunction (may require dose adjustment) 2

Titration Strategy

• Increase dose gradually every 1-2 weeks if blood pressure control is not achieved 1
• If side effects occur, consider maintaining the current dose for a longer period before attempting further increases 1
• For patients with inadequate response to maximum metoprolol dose, consider adding a thiazide diuretic 3

Clinical Pearls

• Metoprolol tartrate requires twice-daily dosing for optimal 24-hour blood pressure control due to its shorter half-life 4
• Metoprolol succinate (extended-release) provides more consistent 24-hour coverage with once-daily dosing 2
• Elderly patients (60-75 years) have shown good response to once-daily dosing of 100 mg metoprolol, with the addition of 12.5 mg hydrochlorothiazide if needed 3, 5
• Do not discontinue metoprolol abruptly; gradual tapering is required to prevent rebound hypertension 1

Expected Response

• Blood pressure typically begins to decrease within the first week of treatment 6
• Full antihypertensive effect may take 2-4 weeks to develop 5
• If inadequate response after 4 weeks at maximum tolerated dose, consider adding a low-dose thiazide diuretic 3

Remember that while starting at a low dose is important to minimize side effects, timely titration is necessary to achieve adequate blood pressure and heart rate control.