What is the most appropriate initial step in managing a 54‑year‑old woman who stopped metoprolol extended‑release 25 mg four months ago, now requests a refill, and presents with dry skin, hair loss, fatigue, amenorrhea for seven months, and occasional hot flashes?

Evaluate for Hypothyroidism Before Refilling Metoprolol

Do not simply refill metoprolol without first obtaining thyroid function tests (TSH, free T4), as this patient's constellation of symptoms—dry skin, hair loss, fatigue, and bradycardia requiring beta-blocker discontinuation—strongly suggests hypothyroidism, which can be exacerbated or unmasked by beta-blockade. 1

Immediate Clinical Assessment

Key Diagnostic Priorities

• Order thyroid function tests immediately (TSH, free T4) before restarting metoprolol, as hypothyroidism causes fatigue, hair loss, dry skin, and can worsen bradycardia when combined with beta-blockers 1

• Verify the original indication for metoprolol by reviewing emergency department records from one year ago—palpitations alone may not justify long-term beta-blocker therapy, especially if the patient stopped without adverse consequences for 4 months 1

• Assess for menopausal symptoms given 7 months of amenorrhea and hot flashes at age 54, which is consistent with perimenopause/menopause and does not require metoprolol 1

Critical Contraindications to Check

Before considering metoprolol reinitiation, verify absence of:

• Symptomatic bradycardia (heart rate <50-60 bpm with dizziness, lightheadedness, or fatigue), which is an absolute contraindication to beta-blocker therapy 1, 2, 3

• Signs of heart failure (new dyspnea, orthopnea, peripheral edema, pulmonary rales), as decompensated heart failure precludes beta-blocker initiation 1, 3

• Hypotension (systolic BP <100 mmHg with symptoms), which contraindicates beta-blocker use 1, 2, 3

Management Algorithm

If Hypothyroidism is Confirmed

• Initiate levothyroxine replacement therapy first before restarting metoprolol, as thyroid hormone replacement will improve fatigue, dry skin, and hair loss within 4-8 weeks 1

• Reassess need for metoprolol after thyroid replacement is optimized (typically 6-8 weeks), as palpitations may have been related to thyroid dysfunction or anxiety rather than a primary cardiac arrhythmia 1

• If metoprolol is still indicated after thyroid optimization, restart at the lowest dose (12.5-25 mg once daily of metoprolol succinate) and titrate slowly while monitoring heart rate and symptoms 2, 3

If Thyroid Function is Normal

• Restart metoprolol at a lower dose than previously prescribed (12.5-25 mg once daily of metoprolol succinate rather than 25 mg of metoprolol ER), as the patient may have been experiencing dose-related bradycardia or fatigue 1, 2

• Target resting heart rate of 50-60 bpm unless limiting side effects occur, and monitor for recurrent fatigue or bradycardia at each visit 1, 2

• Consider alternative explanations for symptoms including iron deficiency anemia (common in perimenopausal women with heavy periods prior to amenorrhea), vitamin D deficiency, or depression 1

Common Pitfalls to Avoid

Do Not Automatically Refill Without Investigation

• Never restart metoprolol without understanding why the patient stopped and whether the original indication was appropriate—many patients are prescribed beta-blockers for benign palpitations that do not require long-term therapy 1

• Avoid attributing all symptoms to menopause without ruling out hypothyroidism, as the two conditions have overlapping symptoms but require different treatments 1

Recognize Medication-Related Fatigue

• Beta-blockers commonly cause fatigue and weakness that may be severe enough to limit dose escalation or require discontinuation, and this side effect can be managed by dose reduction rather than complete cessation 1

• Fatigue from beta-blockers may resolve spontaneously within several weeks without treatment, but persistent fatigue warrants dose reduction or consideration of alternative agents 1

Address Polypharmacy Concerns

• In older adults with multiple symptoms, beta-blockers can interact with other medications (digoxin, calcium channel blockers, amiodarone) to cause additive bradycardia, so review the complete medication list before restarting 1

Monitoring After Reinitiation

• Check heart rate and blood pressure at 1-2 week intervals during dose titration to ensure heart rate remains 50-60 bpm and systolic BP >100 mmHg 1, 2, 3

• Reassess symptoms of fatigue, dry skin, and hair loss at 4-6 weeks to determine if they improve with thyroid replacement (if hypothyroid) or persist despite metoprolol dose adjustment 1

• Monitor TSH every 6-8 weeks if levothyroxine is initiated until thyroid function normalizes, then annually thereafter 1