Tapering Metoprolol for Hypertension
When discontinuing metoprolol in patients treated for hypertension, taper the dose gradually over 1-2 weeks, reducing by approximately 25-50% every 7 days under close clinical surveillance. 1
Rationale for Gradual Tapering
The FDA label explicitly warns against abrupt discontinuation of metoprolol, even in patients treated solely for hypertension, because coronary artery disease may be unrecognized and common in this population 1. Abrupt cessation can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 1. The ACC/AHA guidelines similarly emphasize avoiding abrupt cessation of beta-blockers 2.
Specific Tapering Protocol
For a patient on metoprolol for hypertension, follow this schedule:
- Week 1: Reduce current dose by 50% 3, 1
- Week 2: Reduce to 25% of original dose 3, 1
- Week 3: Discontinue completely if clinically appropriate 3
For example, if a patient is taking metoprolol 100 mg twice daily:
- Week 1: 50 mg twice daily
- Week 2: 25 mg twice daily
- Week 3: Stop
Monitoring During Tapering
Monitor the following parameters at each visit during the tapering process:
- Blood pressure and heart rate to detect rebound hypertension 3
- Symptoms of cardiac ischemia including chest pain, palpitations, or dyspnea 1
- Signs of thyrotoxicosis if patient has thyroid disease, as abrupt withdrawal may precipitate thyroid storm 1
Critical Clinical Pitfalls
Never stop metoprolol abruptly, even in patients without known coronary disease 1. The risk of rebound ischemia exists because:
- Coronary artery disease is common and frequently unrecognized in hypertensive patients 1
- Beta-blocker withdrawal causes upregulation of beta-receptors, leading to increased catecholamine sensitivity 1
Exercise extreme caution if the patient has any of the following:
- Known or suspected coronary artery disease - consider a more gradual taper (25% reductions every 7-14 days) 3
- History of angina or prior myocardial infarction 1
- Concurrent thyroid disease 1
Special Considerations
If angina worsens or acute coronary insufficiency develops during tapering, metoprolol should be reinstated promptly, at least temporarily, and other measures for unstable angina initiated 1. Patients must be warned against interrupting or discontinuing therapy without physician guidance 1.
For patients requiring permanent discontinuation of beta-blocker therapy, consider switching to an alternative antihypertensive class (ACE inhibitor, ARB, or calcium channel blocker) before completing the taper 2.