What is the starting dose of Metoprolol (beta-blocker) for an adult patient with no significant comorbidities?

Metoprolol Starting Dose for Adults

For an adult patient with no significant comorbidities, start metoprolol tartrate at 25-50 mg twice daily for hypertension or angina, or metoprolol succinate extended-release at 50 mg once daily for hypertension. 1

Starting Dose by Indication

Hypertension

• Metoprolol tartrate (immediate-release): Start at 25-50 mg twice daily 1
• Metoprolol succinate (extended-release): Start at 50 mg once daily 1
• Titrate every 1-2 weeks based on blood pressure response, targeting <130/80 mmHg 2
• Maximum dose: 200 mg daily for tartrate, 400 mg daily for succinate 1

Angina Pectoris

• Start at 50 mg twice daily of metoprolol tartrate 1
• Adjust dosing to achieve target resting heart rate of 50-60 beats per minute 1
• Usual maintenance range: 50-200 mg twice daily 1

Atrial Fibrillation Rate Control

• Metoprolol tartrate: Start at 25-50 mg twice daily 3
• Metoprolol succinate: Start at 50 mg once daily 2
• Target resting heart rate <80 bpm (strict control) or <110 bpm (lenient control) 2

Critical Formulation Distinction

Only metoprolol succinate extended-release has proven mortality reduction in heart failure—metoprolol tartrate does not share this benefit and should not be used for heart failure management. 2, 1

• For heart failure with reduced ejection fraction, start metoprolol succinate at 12.5-25 mg once daily 2, 1
• Titrate every 2 weeks to target dose of 200 mg once daily 2, 1
• This formulation reduced all-cause mortality by 34% in the MERIT-HF trial 2, 4

Absolute Contraindications Before Starting

Check for these conditions that preclude metoprolol initiation at any dose: 1

• Signs of heart failure, low output state, or decompensated heart failure 1
• PR interval >0.24 seconds 1
• Second or third-degree heart block without functioning pacemaker 1
• Active asthma or severe reactive airway disease 1
• Systolic blood pressure <100 mmHg with symptoms 3
• Heart rate <50 bpm with symptoms 2

Monitoring After Initiation

• Check blood pressure and heart rate at each visit during titration 2, 3
• Monitor for signs of worsening heart failure: increased dyspnea, weight gain >1.5-2.0 kg over 2 days, peripheral edema 2
• Watch for symptomatic bradycardia (heart rate <60 bpm with dizziness or lightheadedness) 3
• Assess for bronchospasm, particularly in patients with any history of reactive airway disease 3

Common Pitfalls to Avoid

Never abruptly discontinue metoprolol—this can precipitate rebound hypertension, worsening angina, myocardial infarction, and ventricular arrhythmias with up to 50% mortality in some studies. 2, 1

• Beta-blockers are not first-line agents for hypertension unless the patient has coexisting ischemic heart disease or heart failure 2, 1
• Start at the lowest recommended dose and titrate gradually—aggressive initial dosing increases risk of hypotension and bradycardia 2
• For elderly patients or those with hepatic impairment, initiate at low doses with cautious gradual titration 5