What is the appropriate starting dose and titration schedule of metoprolol succinate (extended‑release) for hypertension, including maximum dose and special considerations for elderly patients or those with mild to moderate hepatic impairment?

Metoprolol Succinate ER Dosing for Hypertension

For hypertension, start metoprolol succinate extended-release at 25-50 mg once daily in the morning, titrate every 1-2 weeks as tolerated to a usual maintenance dose of 100-200 mg once daily, with a maximum dose of 200 mg daily. 1

Starting Dose

• Initiate at 25-50 mg once daily for most patients with hypertension 1
• The lower starting dose (25 mg) is preferred in elderly patients (≥80 years), frail patients, or those at risk for hypotension 2
• Take at the most convenient time of day to establish a consistent pattern and improve adherence 2

Titration Schedule

• Double the dose every 1-2 weeks if the preceding dose was well tolerated and blood pressure remains uncontrolled 1
• Monitor blood pressure and heart rate at each titration visit 1
• Target blood pressure control should be achieved within 3 months of initiating therapy 2

Maintenance and Maximum Dosing

• Usual maintenance dose range: 50-200 mg once daily 1
• Maximum recommended dose: 200 mg once daily 1
• The extended-release formulation provides 24-hour blood pressure control with once-daily dosing 3, 4

Special Populations

Elderly Patients (≥80 years)

• Start at 25 mg once daily 2
• Consider monotherapy rather than combination therapy initially 2
• Individualize blood pressure targets based on frailty status 2
• Monitor closely for orthostatic hypotension, bradycardia, and falls 2

Hepatic Impairment (Mild to Moderate)

• No specific dose adjustment is explicitly required in the guidelines for mild to moderate hepatic impairment 1
• However, metoprolol undergoes extensive hepatic metabolism, so start at the lower end of the dosing range (25 mg once daily) and titrate cautiously 5
• Monitor more frequently for signs of excessive beta-blockade (bradycardia, hypotension) 1

Role in Hypertension Treatment Algorithm

Beta-blockers like metoprolol are NOT first-line agents for uncomplicated hypertension 2

• First-line agents are ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics 2
• Beta-blockers are recommended when there are compelling indications such as:
  • Post-myocardial infarction 2
  • Angina pectoris 2
  • Heart failure with reduced ejection fraction 2
  • Heart rate control (e.g., atrial fibrillation) 2
• Metoprolol can be combined with other antihypertensive classes when blood pressure is not controlled on initial therapy 1

Monitoring During Treatment

• Check blood pressure and heart rate at each visit during titration 1
• Monitor for symptomatic bradycardia (heart rate <50-60 bpm with symptoms) 1
• Assess for hypotension (systolic BP <100 mmHg with symptoms of hypoperfusion) 6
• Watch for signs of heart failure exacerbation (fluid retention, dyspnea, weight gain) 1
• Achieve target blood pressure within 3 months 2

Critical Contraindications

Do not initiate metoprolol in patients with: 1

• Second or third-degree heart block without a functioning pacemaker
• PR interval >0.24 seconds
• Active asthma or severe reactive airway disease
• Decompensated heart failure or cardiogenic shock
• Systolic blood pressure <100 mmHg with symptoms
• Heart rate <50 bpm with symptoms

Common Pitfalls to Avoid

Formulation Confusion

• Do NOT confuse metoprolol succinate ER with metoprolol tartrate 1
• Metoprolol tartrate is immediate-release and requires twice-daily dosing (typically 25-100 mg twice daily) 1
• Metoprolol succinate ER is the once-daily formulation proven to reduce mortality in heart failure 1
• Never dose metoprolol succinate ER twice daily—this deviates from evidence-based practice 1

Abrupt Discontinuation

• Never abruptly stop metoprolol—this can precipitate severe angina, myocardial infarction, ventricular arrhythmias, and increased mortality risk (2.7-fold) 6
• If discontinuation is necessary, taper gradually over 1-2 weeks 6

Inadequate 24-Hour Coverage

• Metoprolol succinate ER provides superior early morning blood pressure control compared to atenolol or metoprolol tartrate 4, 7
• The extended-release formulation maintains steady beta-blockade throughout the 24-hour period 3, 4

Combination Therapy Considerations

• When used in combination, metoprolol is typically added to first-line agents (ACE inhibitor/ARB + calcium channel blocker or diuretic) 2
• Metoprolol can be effectively combined with hydrochlorothiazide 12.5 mg for enhanced blood pressure control 8