What is the maximum dose of metoprolol (beta-blocker) for a patient with hypertension, cardiovascular disease, and a history of bacterial skin infections, including Methicillin-resistant Staphylococcus aureus (MRSA) colonization?

Maximum Dose of Metoprolol

For hypertension and cardiovascular disease, the maximum dose of metoprolol tartrate is 200 mg twice daily (400 mg total daily), and for metoprolol succinate extended-release, the maximum dose is 400 mg once daily. 1

Formulation-Specific Maximum Dosing

Metoprolol Tartrate (Immediate-Release)

• The maximum daily dose is 200 mg twice daily for hypertension and cardiovascular conditions 1
• For acute myocardial infarction, the initial IV phase allows up to 15 mg total (three 5 mg boluses given 5 minutes apart), followed by oral dosing of 50 mg every 6 hours for 48 hours, then transitioning to 100 mg twice daily maintenance 1, 2

Metoprolol Succinate (Extended-Release)

• The maximum daily dose is 400 mg once daily for hypertension, atrial fibrillation rate control, and other cardiovascular indications 1, 3
• For heart failure with reduced ejection fraction (HFrEF), the target dose is 200 mg once daily, which represents the evidence-based dose from the MERIT-HF trial that demonstrated 34% mortality reduction 1, 3, 4

Critical Formulation Distinction for Your Patient

Only metoprolol succinate extended-release has proven mortality reduction in heart failure—metoprolol tartrate does not have this evidence and should not be used for heart failure management. 3

• If your patient has any degree of heart failure or reduced ejection fraction, prescribe metoprolol succinate only, with a target dose of 200 mg daily (not the 400 mg maximum) 3
• The 400 mg maximum for metoprolol succinate applies primarily to atrial fibrillation rate control and refractory hypertension, not heart failure 1

Practical Dosing Algorithm

For Hypertension Alone:

• Start metoprolol succinate 50 mg once daily 1
• Titrate every 1-2 weeks based on blood pressure response 1
• Maximum dose: 400 mg once daily 1

For Cardiovascular Disease (Post-MI, Angina):

• Start metoprolol succinate 25-50 mg once daily 1
• Titrate every 2 weeks to target dose of 200 mg daily 1
• Do not exceed 400 mg daily even if blood pressure remains elevated 1

For Heart Failure with Reduced Ejection Fraction:

• Start metoprolol succinate 12.5-25 mg once daily 1, 3
• Double dose every 2 weeks as tolerated 5
• Target dose is 200 mg once daily (this is the goal, not 400 mg) 1, 3
• If target cannot be reached, aim for at least 100 mg daily (50% of target) 1

Important Caveat Regarding MRSA History

The patient's history of bacterial skin infections and MRSA colonization does not affect metoprolol dosing whatsoever. 6

• MRSA treatment involves antibiotics like vancomycin, linezolid, or clindamycin—completely separate from beta-blocker therapy 6
• There are no drug interactions between metoprolol and anti-staphylococcal antibiotics 6
• Continue standard metoprolol dosing protocols regardless of infection history 1

Common Prescribing Pitfall

Do not confuse the maximum dose (400 mg) with the target dose (200 mg) for heart failure patients. The MERIT-HF trial, which demonstrated mortality benefit, used 200 mg daily as the target—higher doses have not been studied for heart failure and offer no additional proven benefit 4. The 400 mg maximum applies to other indications like atrial fibrillation rate control where higher doses may be needed 1.