From the Guidelines
Metoprolol should be prescribed as a twice-daily (BID) medication rather than three times daily (TID), with the extended-release formulation (metoprolol succinate) taken once daily or the immediate-release formulation (metoprolol tartrate) taken twice daily being the preferred options. The standard immediate-release metoprolol tartrate can be dosed TID in certain situations, usually at 25-100 mg per dose, with a total daily dose ranging from 100-400 mg, as seen in the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. However, this TID dosing is less common and may lead to reduced patient adherence compared to once or twice daily regimens. For most patients requiring metoprolol, the pharmacokinetics of metoprolol support these more convenient dosing schedules, as the half-life allows for adequate beta-blockade without requiring three daily doses, as noted in the 2012 ACCF/AHA focused update incorporated into the 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.
Some key points to consider when prescribing metoprolol include:
- The initial dose of metoprolol tartrate can be 25 to 50 mg every 6 to 12 hours orally, then transitioned over the next 2 to 3 days to twice-daily dosing of metoprolol tartrate or to daily metoprolol succinate, with a target dose of 200 mg as tolerated, as recommended in the 2013 ACCF/AHA guideline 1.
- The choice of beta blocker for an individual patient is based primarily on pharmacokinetic and side effect criteria, as well as on physician familiarity, as stated in the 2012 ACCF/AHA focused update 1.
- Metoprolol succinate extended release is preferred for patients with heart failure, with an initial dose of 12.5-25 mg once daily and a maximum dose of 200 mg once daily, as seen in the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1.
- Always administer metoprolol with or immediately after meals to enhance absorption and reduce the risk of orthostatic hypotension.
If a provider has specifically ordered metoprolol TID, it's essential to verify the indication, as certain situations like acute coronary syndromes or difficult-to-control hypertension might occasionally warrant more frequent dosing, as noted in the 2012 ACCF/AHA focused update 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Metoprolol Administration
- Metoprolol is a beta-blocker used to treat various cardiovascular conditions, including hypertension, angina pectoris, and heart failure 2.
- The optimal treatment of hypertension and angina pectoris with metoprolol is achieved through dose titration within the therapeutic range 2.
- A twice-daily dosage regimen is normally used, but satisfactory control can be maintained in many patients with single daily doses of conventional or slow-release formulations 2, 3.
TID (Three Times a Day) Order
- There is no direct evidence to support the use of metoprolol as a TID order in the provided studies.
- However, the studies suggest that metoprolol can be effective in controlling blood pressure and reducing mortality when administered once or twice daily 2, 4, 5, 6, 3.
Dosage and Administration
- The dosage of metoprolol required to achieve satisfactory blood pressure control varies among patients, with an average dosage of 200 mg daily in one study 3.
- The choice of beta-blocker is important, as benefit is not a class-effect, and metoprolol succinate is associated with significant mortality and morbidity benefits in the treatment of heart failure 4, 6.
- Achieving target beta-blocker dose is associated with a better outcome, and the superiority of carvedilol compared to metoprolol tartrate was maintained in a multivariable model 5.