Can Metoprolol Be Stopped Suddenly?
No, metoprolol should never be stopped abruptly—gradual tapering over 1-2 weeks is mandatory to prevent life-threatening complications including severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 1
Critical Warnings About Abrupt Discontinuation
The FDA drug label explicitly warns against abrupt cessation of metoprolol therapy in patients with coronary artery disease, as severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported following sudden discontinuation 1. The American College of Cardiology and American Heart Association guidelines document that beta-blocker withdrawal is associated with a 2.7-fold increased risk of 1-year mortality compared to continuous use 2. In one study, abrupt discontinuation carried a 50% mortality rate 2.
Even in patients treated only for hypertension, it may be prudent not to discontinue metoprolol therapy abruptly because coronary artery disease is common and may be unrecognized 1.
Evidence from Clinical Studies
Research demonstrates the dangers of withdrawal in specific populations:
- In patients with dilated cardiomyopathy receiving metoprolol for ≥30 months, 7 of 13 patients deteriorated after cessation, including 4 who died suddenly or of congestive heart failure during the 4-month period following metoprolol withdrawal 3
- Abrupt withdrawal of metoprolol is associated with a higher risk of developing beta-adrenergic receptor hypersensitivity compared to beta-blockers with intrinsic sympathomimetic activity 4
Recommended Tapering Protocol
The European Heart Journal recommends reducing the dose of metoprolol tartrate by approximately 25-50% every 1-2 weeks 2. When discontinuing chronically administered metoprolol, particularly in patients with coronary artery disease, the dosage should be gradually reduced over a period of 1-2 weeks and the patient should be carefully monitored 1.
Monitoring During Tapering
- Monitor for signs of worsening heart failure symptoms, such as increased fatigue or shortness of breath 2
- Monitor heart rate and blood pressure at each visit 2
- If symptoms worsen during tapering, consider temporarily returning to the previous dose before attempting a more gradual taper 2
Special Considerations for Heart Failure Patients
For patients with heart failure, more cautious tapering may be required with smaller incremental reductions 2. The European Heart Journal recommends considering increasing diuretics or ACE inhibitors temporarily if worsening of heart failure occurs during tapering 2.
When Metoprolol Must Be Reinstated
If angina markedly worsens or acute coronary insufficiency develops during tapering, metoprolol administration should be reinstated promptly, at least temporarily, and other measures appropriate for the management of unstable angina should be taken 1. Patients should be warned against interruption or discontinuation of therapy without the physician's advice 1.
Common Pitfalls to Avoid
- Never stop metoprolol abruptly, even for symptomatic bradycardia or hypotension—dose reduction is preferred over complete cessation 2
- Do not assume that patients without known coronary disease are safe from withdrawal complications—unrecognized coronary artery disease is common 1
- Avoid complete discontinuation in heart failure patients—maintaining some beta-blockade at lower doses is better than no beta-blocker, as complete discontinuation increases mortality risk 2.7-fold 2