What is the equivalent dosage of Nebivolol (beta-blocker) when switching from Metoprolol (beta-blocker)?

Nebivolol to Metoprolol Dosage Equivalence

When switching from metoprolol to nebivolol, use a 10:1 conversion ratio - metoprolol 50 mg is equivalent to nebivolol 5 mg. 1

Dosage Equivalence Based on Guidelines

• According to the European Society of Cardiology guidelines, the target dose of metoprolol succinate (CR/XL) is 200 mg once daily, while the target dose for nebivolol is 10 mg once daily 2
• The recommended starting dose for nebivolol is 1.25 mg once daily, compared to metoprolol succinate's starting dose of 12.5-25 mg once daily 2
• The American College of Cardiology/American Heart Association guidelines indicate that nebivolol's usual dosage range is 5-40 mg daily 2

Conversion Protocol

• When transitioning from metoprolol to nebivolol, follow this conversion:
  • Metoprolol 50 mg = Nebivolol 5 mg 1
  • Metoprolol 100 mg = Nebivolol 10 mg 1
• For patients on metoprolol tartrate 50 mg, initiate nebivolol at 5 mg once daily 1
• For patients on higher doses of metoprolol (e.g., 200 mg daily), start with nebivolol 10 mg (maximum recommended dose) 2, 1

Clinical Considerations When Switching

• Both medications are beta-1 selective blockers, but nebivolol has additional nitric oxide-mediated vasodilatory effects 3
• Nebivolol is administered once daily, similar to metoprolol succinate (CR/XL), but different from metoprolol tartrate which is typically given twice daily 2
• Acute hemodynamic studies show that nebivolol 5 mg produces similar heart rate reduction as metoprolol tartrate 50 mg, supporting this dose equivalence 4

Pharmacological Differences to Consider

• Unlike metoprolol, nebivolol causes a decrease in systemic vascular resistance due to its nitric oxide-mediated vasodilatory effects 4
• Nebivolol may have more favorable effects on insulin sensitivity compared to metoprolol, which could be relevant in patients with metabolic syndrome 5
• Both medications effectively lower blood pressure to a similar extent when used at equivalent doses 3, 6

Monitoring After Switching

• Monitor heart rate and blood pressure within 1-2 weeks after switching to ensure adequate beta-blockade 1
• Watch for signs of bradycardia, which can occur with both medications 4
• Dose titration should occur at 2-4 week intervals if needed, monitoring for symptomatic hypotension or bradycardia 1

Common Pitfalls to Avoid

• Avoid abrupt discontinuation of either medication, as this can lead to rebound hypertension or worsening of cardiac symptoms 2, 1
• Do not exceed the maximum recommended dose of nebivolol (10 mg daily) even if the patient was on a higher dose of metoprolol 2, 1
• Remember that nebivolol has different metabolic effects than metoprolol, which may be beneficial in patients with erectile dysfunction or metabolic syndrome 7, 5