What is the maximum recommended dose of Metoprolol (metoprolol succinate ER) for patients with hypertension or heart failure?

Maximum Dose of Metoprolol Succinate ER

The maximum recommended dose of metoprolol succinate extended-release is 200 mg once daily for both heart failure and hypertension. 1

Evidence-Based Maximum Dosing

• The 200 mg once-daily dose is the established ceiling based on the landmark MERIT-HF trial, which demonstrated a 34% reduction in all-cause mortality at this target dose in heart failure patients. 2

• This maximum applies across indications, though the FDA label notes that hypertension dosing can range from 50-400 mg once daily in clinical practice. 3

• For heart failure specifically, 200 mg once daily is both the maximum and target dose, with no evidence supporting higher doses and potential harm from exceeding this amount. 1

Dosing Context by Indication

Heart Failure with Reduced Ejection Fraction

• Start at 12.5-25 mg once daily (lower dose for NYHA class III-IV, higher for class II). 1
• Double the dose every 1-2 weeks as tolerated during titration. 1
• Target and maximum dose: 200 mg once daily. 1
• In the MERIT-HF trial, 64% of patients achieved the full 200 mg target dose, with a mean achieved dose of 159 mg daily. 1, 4

Hypertension

• Typical starting dose: 25-50 mg once daily. 1
• Usual therapeutic range: 50-200 mg once daily. 1
• While the FDA label mentions doses up to 400 mg daily for hypertension, guideline-based practice supports 200 mg as the practical maximum, as higher doses provide minimal additional benefit with increased side effects. 3, 1

Critical Formulation Distinction

Only metoprolol succinate extended-release (ER/CR/XL) should be used for heart failure—metoprolol tartrate (immediate-release) has not demonstrated mortality reduction and should not be substituted. 1

• The sustained-release formulation allows once-daily dosing and provides consistent beta-blockade over 24 hours. 1
• Metoprolol tartrate requires twice-daily dosing and showed inferior outcomes compared to carvedilol in the COMET trial. 1

Monitoring During Dose Escalation

• Monitor heart rate (target >50 bpm with symptoms), blood pressure (avoid symptomatic hypotension), and signs of fluid retention at each titration step. 1
• If worsening congestion occurs, first increase diuretics before reducing the beta-blocker dose. 1
• For symptomatic bradycardia (<50 bpm with symptoms), halve the dose rather than discontinue. 1

Common Pitfalls

Never abruptly discontinue metoprolol succinate, as this can precipitate rebound myocardial ischemia, infarction, and arrhythmias—taper gradually over one week if discontinuation is necessary. 1

• Underdosing is common due to fear of side effects; aim for at least 50% of target dose (100 mg daily minimum) if the full 200 mg cannot be tolerated, as dose-response relationships exist for mortality benefit. 5

• Do not initiate in patients with decompensated heart failure, cardiogenic shock, or severe bradycardia/heart block. 1

• The maximum of 200 mg once daily applies regardless of whether the patient has heart failure, hypertension, or both conditions simultaneously. 1