From the Guidelines
The target dose of metoprolol succinate for most cardiovascular conditions is typically 200 mg once daily, though this should be individualized based on patient response and tolerance. Treatment usually begins with a lower dose of 25-50 mg once daily, with gradual increases every 1-2 weeks until reaching the target dose or maximum tolerated dose. For heart failure patients, the target dose is specifically 200 mg once daily based on clinical trial evidence showing mortality benefits at this dose 1. For hypertension, doses may range from 50-200 mg once daily, while for angina or post-myocardial infarction, 200 mg daily is generally recommended. Metoprolol succinate is an extended-release formulation that should be taken once daily, preferably in the morning, and can be taken with or without food. The medication works by blocking beta-1 adrenergic receptors, reducing heart rate and contractility, which decreases myocardial oxygen demand and improves outcomes in cardiovascular conditions. Dose adjustments may be necessary for elderly patients or those with renal or hepatic impairment. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults, metoprolol succinate is a preferred beta-blocker for patients with heart failure, with a recommended dose of 50-200 mg once daily 2.
Some key points to consider when prescribing metoprolol succinate include:
- Starting with a lower dose and gradually increasing as needed and tolerated
- Monitoring for signs of worsening heart failure, symptomatic hypotension, or excessive bradycardia
- Adjusting the dose based on patient response and tolerance
- Considering alternative beta-blockers, such as bisoprolol or carvedilol, in certain patient populations
- Being aware of potential drug interactions, such as with other beta-blockers or calcium channel blockers.
It's also important to note that metoprolol succinate should be avoided in patients with certain conditions, such as decompensated heart failure, hypotension, or reactive airway disease, and should be used with caution in patients with renal or hepatic impairment 3, 4.
From the Research
Target Dose of Metoprolol Succinate
- The target dose of metoprolol succinate is 200 mg once daily, as demonstrated in the MERIT-HF trial 5.
- In this trial, 64% of patients reached the target dose of 200 mg once daily, and 87% reached a dose of 100 mg or more.
- The study suggests that the target dose should be strived for in all patients who tolerate this dose.
Efficacy of Metoprolol Succinate
- Metoprolol succinate has been shown to reduce total mortality by 34% and total mortality plus all-cause hospitalization by 19% in patients with heart failure 5.
- The drug has also been found to be effective in reducing heart rate in patients with stable angina and elevated heart rate receiving low-dose β-blocker therapy 6.
- However, the efficacy of metoprolol succinate compared to other beta-blockers, such as bisoprolol and carvedilol, is still a topic of debate, with some studies suggesting similar effects on mortality 7.
Dosing and Tolerability
- The initial dose of metoprolol succinate should be very low, with gradual increases over weeks to the target dose 8.
- The drug has been found to be well tolerated, with minimal side effects or deterioration, even in high-risk patients such as the elderly and those with severe heart failure 5.
- However, patients with certain conditions, such as bronchospasm, may require reduced doses or temporary withholding of the drug 8.