What is the recommended tapering period for metoprolol (beta blocker)?

Metoprolol Tapering Duration

Metoprolol should be tapered gradually over 1-2 weeks when discontinuing therapy, particularly in patients with coronary artery disease, to prevent severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 1

Standard Tapering Protocol

The European Heart Journal recommends reducing metoprolol tartrate by approximately 25-50% every 1-2 weeks until complete discontinuation. 2 This gradual approach minimizes the risk of rebound cardiovascular events that can occur with abrupt cessation.

Recommended Tapering Schedule

• Reduce the dose by 25-50% every 7-14 days under close clinical surveillance 2, 3
• Monitor heart rate, blood pressure, and symptoms of worsening angina or heart failure at each step 2
• If symptoms worsen during tapering, temporarily return to the previous dose before attempting a more gradual taper 2

For example, if a patient is on metoprolol 100 mg twice daily:

• Week 1-2: Reduce to 50 mg twice daily 2
• Week 3-4: Reduce to 25 mg twice daily 2
• Week 5-6: Discontinue completely 2

Critical Warnings About Abrupt Discontinuation

The FDA drug label explicitly warns against abrupt discontinuation of metoprolol in patients with coronary artery disease, as severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported. 1 The ACC/AHA guidelines document that beta-blocker withdrawal is associated with a 2.7-fold increased risk of 1-year mortality compared to continuous use, and abrupt discontinuation can cause a 50% mortality rate in some studies. 2

Special Considerations for Different Patient Populations

Patients with Heart Failure

• More cautious tapering may be required with smaller incremental reductions (25% every 1-2 weeks) 2
• Consider temporarily increasing diuretics or ACE inhibitors if worsening heart failure occurs during tapering 2
• Monitor for signs of worsening heart failure including increased fatigue, shortness of breath, weight gain, and peripheral edema 2

Patients with Coronary Artery Disease

• Exercise extreme caution and use the most gradual tapering schedule possible (reductions of 25% every 7-14 days) 3
• Close cardiac monitoring is essential due to particularly high risk of rebound ischemia, infarction, and arrhythmias 3
• If angina markedly worsens during tapering, metoprolol should be reinstated promptly, at least temporarily 1

Patients with Hypertension Only

• Standard 1-2 week taper is generally sufficient 1
• However, because coronary artery disease may be unrecognized, it is prudent not to discontinue metoprolol abruptly even in patients treated only for hypertension 1

Monitoring During Tapering

Essential monitoring parameters include: 2

• Heart rate and blood pressure at each visit during the tapering process
• Signs of worsening heart failure (dyspnea, fatigue, edema, weight gain >1.5-2.0 kg over 2 days)
• Symptoms of myocardial ischemia (chest pain, shortness of breath)
• ECG changes if clinically indicated

Common Pitfalls to Avoid

• Never stop metoprolol abruptly, even for compelling reasons—always taper gradually 1
• Do not assume that patients without known coronary disease are safe for rapid discontinuation—occult coronary disease is common 1
• Avoid tapering too quickly in patients with heart failure or coronary disease—use smaller dose reductions (25%) over longer intervals (2 weeks) 2, 3
• Do not ignore worsening symptoms during tapering—be prepared to slow the taper or temporarily increase the dose 2

Alternative to Complete Discontinuation

If metoprolol must be reduced due to side effects but not completely discontinued, maintaining the patient on the lowest tolerated dose is preferable to complete cessation, as some beta-blocker is better than no beta-blocker. 3 The ACC/AHA guidelines emphasize that even lower doses provide mortality benefit in heart failure patients. 3