From the Guidelines
Transitioning from metoprolol to an ACE inhibitor should be done gradually under medical supervision, with a slow reduction of metoprolol dose over 1-2 weeks while monitoring blood pressure and heart rate, followed by initiation of the ACE inhibitor at a low dose and gradual increase as needed, as recommended by the most recent guidelines 1. When tapering off metoprolol, it's essential to monitor blood pressure and heart rate closely to avoid rebound hypertension or worsening angina. The metoprolol dose can be reduced by half every few days, for example, from 50mg twice daily to 25mg twice daily, then to 25mg once daily, before stopping completely. Once metoprolol is discontinued, the ACE inhibitor can be started at a low dose, such as lisinopril 2.5-5mg once daily, and increased gradually every 2-4 weeks as needed and tolerated, up to a maximum dose of 10-40mg daily, as recommended by the European Society of Cardiology guidelines 1. The key considerations during this transition include:
- Monitoring blood pressure, renal function, and electrolytes regularly, especially after each dose increment
- Avoiding excessive diuresis before treatment and reducing or withholding diuretics if necessary
- Starting treatment in the evening, if possible, to minimize potential negative effects on blood pressure
- Avoiding potassium-sparing diuretics and non-steroidal anti-inflammatory drugs (NSAIDs) during initiation of therapy
- Checking blood chemistry, including urea, creatinine, and potassium, 1-2 weeks after initiation and 1-2 weeks after final dose titration, and monitoring blood chemistry 4 monthly thereafter, as recommended by the guidelines 1.