What medication is equivalent to esmolol (beta blocker) for a push dose?

Push-Dose Beta Blocker Equivalent to Esmolol

Metoprolol is the most appropriate push-dose alternative to esmolol, administered as 2.5-5 mg IV bolus over 2 minutes, which can be repeated every 5-10 minutes up to a maximum of 15 mg. 1

Rationale for Metoprolol as First Alternative

Metoprolol provides the same beta-1 selective blockade as esmolol with a similarly rapid onset (1-2 minutes versus esmolol's 1-2 minutes), making it the guideline-recommended alternative across multiple clinical scenarios. 1

• The 2019 ESC Hypertensive Emergencies guideline explicitly lists metoprolol alongside esmolol as equivalent options for IV beta-blockade, both with 1-2 minute onset times 1
• The 2015 ACC/AHA/HRS SVT guidelines position metoprolol and esmolol interchangeably for acute rate control, with identical Class I recommendations 1
• Both agents share the same contraindications: second or third-degree AV block, systolic heart failure, asthma, and bradycardia 1

Key Pharmacologic Differences

The critical distinction is duration of action: metoprolol lasts 5-8 hours versus esmolol's 10-30 minutes, eliminating the titratable reversibility that makes esmolol unique. 1, 2, 3

• Esmolol's ultra-short half-life (9 minutes) allows complete recovery from beta-blockade within 18-30 minutes of stopping infusion 3, 4
• Metoprolol's longer duration means adverse effects (hypotension, bradycardia) cannot be rapidly reversed by simply stopping the drug 1
• This makes metoprolol less ideal in hemodynamically unstable patients where you may need to quickly "turn off" beta-blockade 1, 5

Alternative Options When Metoprolol Insufficient

Propranolol (1 mg IV over 1 minute, repeated every 2 minutes up to 3 doses) serves as a second-line push-dose option, though it lacks beta-1 selectivity. 1

• Propranolol has the same 1-2 minute onset as metoprolol but is non-selective, increasing risk of bronchospasm in reactive airway disease 1
• The 2011 ACC/AHA/HRS AF guidelines list propranolol with identical Class I recommendation as metoprolol for acute rate control 1

Labetalol (0.25-0.5 mg/kg IV bolus or 2.5-5 mg repeated every 10 minutes) provides combined alpha and beta blockade but has slower onset (5-10 minutes). 1

• The 2019 ESC guideline identifies labetalol as "the drug of choice" for acute BP reduction in hypertensive emergencies with acute coronary events 1
• Labetalol's alpha-blocking properties provide additional afterload reduction beneficial in hypertensive crises 1
• Duration of action is 3-6 hours, similar to metoprolol 1

Clinical Pitfalls to Avoid

Never use IV beta-blockers as push doses in patients with decompensated heart failure, cardiogenic shock, or severe hypotension—these are absolute contraindications across all guidelines. 1

• The 2011 ACC/AHA Unstable Angina guidelines specifically downgraded early IV beta-blocker use in hemodynamically unstable patients, recommending oral initiation instead 1
• In acute heart failure with pulmonary congestion beyond basal rales, beta-blockers should be used "cautiously" and only when ongoing ischemia with tachycardia is present 1

Avoid push-dose beta-blockers in patients with reactive airway disease—the brief exposure doesn't justify the bronchospasm risk when alternatives exist. 1

Practical Dosing Algorithm

For acute rate control or hypertension requiring immediate beta-blockade:

• First choice: Metoprolol 2.5-5 mg IV over 2 minutes 1
• Reassess after 5 minutes: If inadequate response and hemodynamically stable, repeat 2.5-5 mg 1
• Maximum total dose: 15 mg over 10-15 minutes 1
• If unstable or need reversibility: Use esmolol infusion (500 mcg/kg bolus, then 50-300 mcg/kg/min) instead of any push-dose agent 1, 2

In situations requiring the unique titratable reversibility of esmolol (critical care, perioperative settings, uncertain hemodynamics), no true push-dose equivalent exists—you must use esmolol infusion. 2, 3, 4, 5