What is the maximum recommended dose of metoprolol (beta blocker) per day?

Maximum Recommended Dose of Metoprolol Per Day

The maximum recommended daily dose of metoprolol succinate (extended-release) is 200 mg once daily, while metoprolol tartrate (immediate-release) can be administered up to 400 mg daily in divided doses. 1

Metoprolol Formulations and Maximum Dosing

• Metoprolol Succinate (Extended-Release):

  • Maximum dose: 200 mg once daily 1
  • Allows for once-daily dosing due to extended-release formulation 1, 2
  • Provides consistent beta-blockade over 24 hours without marked peaks and troughs 2

• Metoprolol Tartrate (Immediate-Release):

  • Typically administered in divided doses due to shorter half-life 1
  • For hypertension: 100-450 mg daily in divided doses 3
  • For post-MI maintenance: 100 mg twice daily (200 mg total) 1

Condition-Specific Maximum Dosing

• Heart Failure:

  • Target dose: 200 mg once daily (metoprolol succinate) 1
  • In clinical trials, mean dose achieved was 159 mg daily 1
  • MERIT-HF trial demonstrated significant mortality reduction with target dose of 200 mg once daily 4

• Hypertension:

  • Dose range: 50-400 mg once daily (metoprolol succinate) 1
  • For immediate-release formulation: 100-450 mg daily in divided doses 3

• Post-Myocardial Infarction:

  • Maintenance dose: 100 mg twice daily (metoprolol tartrate) 1
  • Initial oral therapy after IV administration: 25-50 mg every 6 hours for 48 hours 5

Important Dosing Considerations

• Titration Protocol:

  • Start with low dose (12.5-25 mg once daily for succinate; 25-50 mg twice daily for tartrate) 1
  • Gradually increase dose every 1-2 weeks if well tolerated 1
  • For heart failure patients, initial dose should be 12.5-25 mg once daily 1

• Special Populations:

  • Hepatic Impairment: Dosage reduction may be necessary as elimination half-life can be prolonged up to 7.2 hours 3
  • Renal Impairment: No significant dose adjustment typically needed 3
  • Poor CYP2D6 Metabolizers: May have 7-9 hour half-life versus 3-4 hours in normal metabolizers 3

Contraindications and Precautions

• Do not initiate in patients with:

  • Signs of heart failure or low output state 5, 1
  • Increased risk for cardiogenic shock 5
  • Significant bradycardia (heart rate <50 bpm) 5
  • Hypotension (systolic BP <90 mmHg) 5

• Use caution in patients with:

  • Chronic obstructive pulmonary disease with reactive airway component (start with low dose of 12.5 mg) 5
  • Tachycardia or Killip Class II or III, which increases risk of cardiogenic shock 5

Common Pitfalls to Avoid

• Never abruptly discontinue metoprolol as this may precipitate angina, myocardial infarction, or arrhythmias 1
• Avoid initiating in decompensated heart failure patients 1
• Monitor for bradycardia, hypotension, and worsening heart failure symptoms during dose titration 1
• For patients transitioning from immediate-release to extended-release formulation, 200 mg of metoprolol succinate CR/XL provides similar beta-blockade to 50 mg three times daily of immediate-release metoprolol 6