From the Guidelines
Metoprolol can accumulate in patients with renal failure, but the effect is generally modest. According to the most recent and highest quality study available 1, metoprolol is considered slightly dialyzable, which implies that it may accumulate in patients with renal failure. However, metoprolol is primarily metabolized by the liver, with only about 5-10% of the drug being eliminated unchanged by the kidneys. Some key points to consider when prescribing metoprolol to patients with renal failure include:
- Starting with lower doses, such as 25-50 mg twice daily for immediate-release instead of 100 mg, and titrating based on blood pressure response and heart rate control.
- Monitoring patients for signs of beta-blocker toxicity, including bradycardia, hypotension, bronchospasm, or worsening heart failure.
- Considering the use of the extended-release formulation (metoprolol succinate), which may provide more stable blood levels in patients with renal impairment. It's also important to note that the accumulation of metoprolol in renal failure is generally not significant enough to require dose adjustment in most cases, as supported by guidelines from the American College of Cardiology/American Heart Association 1.
From the FDA Drug Label
The systemic availability and half-life of metoprolol in patients with renal failure do not differ to a clinically significant degree from those in normal subjects. No dose adjustment of metoprolol tartrate is required in patients with renal impairment
Metoprolol does not accumulate in renal failure to a clinically significant degree.
- The systemic availability and half-life of metoprolol in patients with renal failure are similar to those in normal subjects 2.
- No dose adjustment is required in patients with renal impairment 2.
From the Research
Metoprolol Accumulation in Renal Failure
- Metoprolol accumulation in renal failure has been studied in several research papers 3, 4, 5.
- A study published in 1980 found that significant accumulation of metoprolol was only observed in patients with a glomerular filtration rate (GFR) of about 5 ml/min 3.
- Another study from 1980 found no significant differences in the extent of bioavailability or rate of elimination of metoprolol between patients with renal impairment and healthy subjects 4.
- A 2005 study investigated the influence of chronic renal failure on the stereoselective metabolism of metoprolol and found that patients with chronic renal failure presented plasma accumulation of metoprolol acidic metabolite enantiomers 5.
Renal Impairment and Metoprolol Efficacy
- A 2019 study found that beta-blockers, including metoprolol, are effective in patients with heart failure and reduced ejection fraction, even with moderate or moderately severe renal dysfunction 6.
- However, the study noted that there were insufficient patients with severe renal dysfunction (eGFR <30 ml/min/1.73 m2) to draw conclusions 6.
- A 2010 study compared the effects of carvedilol and metoprolol on renal function in patients with heart failure and found that metoprolol decreased eGFR, while carvedilol did not 7.
Key Findings
- Metoprolol accumulation is significant only in patients with severe renal impairment (GFR <5 ml/min) 3.
- Metoprolol is effective in patients with heart failure and reduced ejection fraction, even with moderate or moderately severe renal dysfunction 6.
- The choice of beta-blocker may affect renal function, with carvedilol potentially being preferable to metoprolol in patients with higher baseline eGFR 7.