How do I safely discontinue metoprolol in a patient taking 25mg with other antihypertensives?

Safe Discontinuation of Metoprolol 25mg in Patients on Combination Antihypertensives

Metoprolol should never be stopped abruptly—taper the dose by 50% (to 12.5mg daily) for 1-2 weeks before complete discontinuation, while closely monitoring for rebound hypertension, tachycardia, and cardiac symptoms. 1, 2

Critical Warning About Abrupt Discontinuation

• The FDA explicitly warns against abrupt cessation of metoprolol, particularly in patients with coronary artery disease, as this can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 2
• Even in patients treated only for hypertension, abrupt discontinuation is dangerous because coronary artery disease may be unrecognized and present. 2
• Beta-blocker withdrawal carries a 2.7-fold increased risk of 1-year mortality compared to continuous use, with one study documenting 50% mortality after abrupt discontinuation. 3

Recommended Tapering Protocol

Step 1: Reduce to half-dose for 1-2 weeks

• Decrease metoprolol from 25mg daily to 12.5mg daily for 10-14 days. 1, 3, 2
• This prolonged low-dose schedule prevents enhanced beta-adrenergic sensitivity and rebound phenomena that occur 2-8 days after abrupt withdrawal. 4

Step 2: Monitor during taper

• Check blood pressure and heart rate at baseline, mid-taper (week 1), and before complete discontinuation. 3
• Watch for rebound hypertension (BP increase >20/10 mmHg above baseline), tachycardia (HR >15 bpm above baseline), or withdrawal symptoms including headache, palpitations, tremor, and increased angina. 4, 5
• Daily weights to detect fluid retention if patient has underlying heart failure. 1

Step 3: Complete discontinuation

• After 1-2 weeks at 12.5mg daily, stop metoprolol completely. 2
• Continue monitoring for an additional 2 weeks post-discontinuation, as rebound phenomena can persist for 8-14 days. 4, 5

Managing Other Antihypertensives During Taper

Before reducing metoprolol:

• Ensure other antihypertensives are optimized to maintain BP control during and after beta-blocker withdrawal. 1
• Consider temporarily increasing diuretic dose if signs of fluid retention develop during taper. 1

Do not discontinue:

• ACE inhibitors, ARBs, or other vasodilators should remain at current doses unless symptomatic hypotension occurs. 1
• If patient becomes hypotensive during taper, reduce vasodilators (nitrates, calcium channel blockers) first before further adjusting metoprolol. 1

High-Risk Situations Requiring Extra Caution

Patients who need slower taper (reduce by 25% every 2 weeks instead):

• Known coronary artery disease or history of myocardial infarction. 2
• Heart failure with reduced ejection fraction (even if compensated). 1
• High doses of multiple antihypertensive drugs. 6
• Severe or renovascular hypertension. 6

If withdrawal syndrome develops:

• Immediately reinstate metoprolol at the previous dose. 2, 6
• This is the most appropriate treatment for discontinuation syndrome. 6
• Seek specialist cardiology consultation before attempting another taper. 1

Common Pitfalls to Avoid

• Never stop metoprolol suddenly "because the dose is low"—even 25mg daily requires tapering, as withdrawal phenomena are related to duration of therapy and individual beta-adrenergic sensitivity, not just dose. 4, 5
• Do not assume other antihypertensives will prevent rebound—beta-blocker withdrawal causes specific adrenergic hypersensitivity that other drug classes cannot prevent. 4
• Do not taper too quickly—serial dose reduction over 6-9 days decreases but does not prevent cardiac hypersensitivity; the prolonged low-dose schedule (10-14 days) is superior. 7, 4
• Monitor beyond the taper period—rebound phenomena peak 2-8 days after complete withdrawal and can persist up to 14 days. 4, 5

When Complete Discontinuation May Not Be Advisable

• If patient has underlying coronary disease, consider switching to another beta-blocker rather than complete discontinuation. 2
• If heart failure is present, beta-blocker therapy provides mortality benefit and should rarely be stopped—seek specialist advice before discontinuation. 1, 8
• If patient develops marked worsening of angina during taper, reinstate metoprolol immediately and use alternative measures for blood pressure control. 2