Metoprolol Dosing Table
Hypertension
Metoprolol Tartrate (Immediate-Release)
- Initial dose: 25–50 mg twice daily 1
- Maintenance: 100–200 mg daily (divided into two doses) 1
- Maximum: 200 mg twice daily (400 mg total daily) 1
- Titration interval: Every 1–2 weeks based on blood pressure response 1
Metoprolol Succinate (Extended-Release)
- Initial dose: 50 mg once daily 1
- Maintenance: 50–200 mg once daily 1
- Maximum: 400 mg once daily 1
- Titration interval: Every 1–2 weeks based on blood pressure response 1
Chronic Stable Angina
Metoprolol Succinate (Extended-Release)
- Initial dose: 50–100 mg once daily 1
- Target dose: 200 mg once daily 1
- Maximum: 400 mg once daily 1
- Titration: Gradually increase every 1–2 weeks as tolerated 1
Acute Myocardial Infarction
Intravenous Phase (Early Administration)
- Initial IV dose: 5 mg slow IV bolus over 1–2 minutes 1
- Repeat: 5 mg IV every 5 minutes as needed 1
- Maximum total IV dose: 15 mg (three 5 mg boluses) 1
Critical contraindications before IV administration: Signs of heart failure, low output state, systolic BP <120 mmHg, heart rate >110 bpm or <60 bpm, PR interval >0.24 seconds, second or third-degree heart block, active asthma, age >70 years with risk factors for cardiogenic shock 1
Transition to Oral Therapy
- Begin oral metoprolol tartrate 15 minutes after last IV dose 1
- Initial oral dose: 25–50 mg every 6 hours for 48 hours 1
- Maintenance: Transition to 100 mg twice daily after initial 48-hour period 1
Long-Term Secondary Prevention (Post-MI)
- Metoprolol succinate 200 mg once daily is the target dose for secondary prevention 1
- Initial dose: 12.5–25 mg once daily, titrated gradually every 2 weeks 1
Supraventricular Tachycardia (Including Atrial Fibrillation)
Intravenous Administration
- Initial dose: 5 mg IV over 1–2 minutes 1
- Repeat: Every 5 minutes as required based on heart rate and blood pressure 1
- Maximum total dose: 15 mg 1
Oral Maintenance (Atrial Fibrillation Rate Control)
- Metoprolol tartrate: 25–100 mg twice daily 1
- Metoprolol succinate: 50–400 mg once daily 1
- Target resting heart rate: 50–80 bpm (strict control) or <110 bpm (lenient control) 1
Heart Failure with Reduced Ejection Fraction (HFrEF)
Metoprolol Succinate (Extended-Release) – ONLY Evidence-Based Formulation
- Initial dose: 12.5–25 mg once daily 1
- Titration: Double the dose every 2 weeks if well tolerated 1
- Target dose: 200 mg once daily 2, 1
- Mean effective dose in trials: 159 mg daily 1
Critical principle: Metoprolol tartrate (immediate-release) has never demonstrated mortality benefit in heart failure trials and must not be used as a substitute for metoprolol succinate 2. Only metoprolol succinate 200 mg once daily has proven mortality reduction in heart failure 2.
Monitoring During Titration
- Monitor at each visit: Heart rate, blood pressure, signs of worsening heart failure 1
- Target resting heart rate: 50–60 bpm unless limiting side effects occur 1
- If symptoms worsen: Increase diuretics or ACE inhibitors before reducing beta-blocker dose 2
Post-Myocardial Infarction Secondary Prevention
Metoprolol Succinate (Extended-Release)
- Initial dose: 12.5–25 mg once daily 1
- Target dose: 200 mg once daily 1
- Titration: Gradually increase every 2 weeks to reach target 1
Special Populations & Dosing Considerations
Women
- Women may achieve optimal outcomes at 50% of guideline-recommended doses due to 50–80% higher metoprolol exposure compared to men 1
- Consider starting at lower doses (e.g., 12.5 mg) and titrating more cautiously 1
Elderly Patients
- Start at the lowest recommended dose (12.5–25 mg) 1
- Titrate more slowly with careful monitoring for hypotension and bradycardia 1
Absolute Contraindications (All Indications)
- Decompensated heart failure or signs of low cardiac output 1
- Second or third-degree AV block without functioning pacemaker 1
- Symptomatic bradycardia (heart rate <50–60 bpm with symptoms) 1
- Symptomatic hypotension (systolic BP <100 mmHg with symptoms) 1
- Active asthma or severe reactive airway disease 1
- Cardiogenic shock 1
Critical Warnings
Never abruptly discontinue metoprolol: Sudden withdrawal can precipitate severe angina, myocardial infarction, ventricular arrhythmias, and a 2.7-fold increased risk of 1-year mortality 1. Always taper gradually over 1–2 weeks by reducing the dose by 25–50% every 1–2 weeks 1.
Formulation matters in heart failure: Only bisoprolol, metoprolol succinate, and carvedilol have proven mortality benefit; beta-blockers cannot be considered interchangeable on a class-effect basis 2.