What is the equivalent dose of carvedilol (generic) for a patient taking metoprolol tartrate (Lopressor) 100 milligrams daily?

From the Guidelines

When converting from metoprolol tartrate 100 mg daily to carvedilol, the recommended equivalent dose is carvedilol 25 mg twice daily (50 mg total daily dose), as this is the target dose mentioned in the most recent and highest quality study 1. This conversion should be done gradually, with visits every 2-4 weeks to up-titrate the dose of beta-blocker, as recommended by the European Society of Cardiology 1.

• The dose of carvedilol should be increased gradually, starting with a low dose, such as 6.25 mg twice daily, and then doubled at each visit until the target dose is reached or the maximum tolerated dose is achieved.
• Patients should be monitored for signs of worsening heart failure, symptomatic hypotension, or excessive bradycardia at each visit, and the dose should not be increased if any of these conditions are present 1.
• Carvedilol has additional alpha-blocking properties that metoprolol lacks, which may cause more pronounced blood pressure lowering effects, so patients should monitor their blood pressure and heart rate regularly during the transition.
• The conversion is based on relative potency, with carvedilol being approximately 4 times more potent than metoprolol on a milligram basis, as mentioned in the example answer.
• Patients should be aware that carvedilol may cause different side effects than metoprolol, including more pronounced dizziness upon standing due to its alpha-blocking effects. The American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines also recommends individualizing the dose of beta-blockers, such as metoprolol and carvedilol, and titrating to a daily dose of 200 mg as tolerated for metoprolol, and 25 mg twice daily as tolerated for carvedilol 1.

From the Research

Conversion from Metoprolol Tartrate to Carvedilol

• The conversion from metoprolol tartrate to carvedilol is a common practice in the treatment of heart failure and hypertension, as both medications are beta-blockers but have different pharmacological properties 2, 3.
• Studies have shown that carvedilol and metoprolol have similar efficacy in improving symptoms, exercise capacity, and left ventricular ejection fraction in patients with heart failure 3, 4.
• However, carvedilol has been found to have a greater effect on lowering blood pressure and improving left ventricular dimensions compared to metoprolol 3, 5.
• The choice between carvedilol and metoprolol depends on individual patient characteristics, such as renal function and the presence of comorbidities 5, 6.
• A study found that carvedilol may be preferable to metoprolol in patients with lower baseline estimated glomerular filtration rate (eGFR) to prevent the development of chronic kidney disease 5.

Dosing Considerations

• When converting from metoprolol tartrate to carvedilol, the dosing should be individualized based on patient response and tolerance 3, 4.
• A common conversion ratio is to start with a lower dose of carvedilol (e.g., 12.5-25 mg twice daily) and titrate up as needed and tolerated 3, 6.
• The maximum recommended dose of carvedilol is 50 mg twice daily, while the maximum recommended dose of metoprolol tartrate is 200-400 mg daily 2, 4.

Clinical Implications

• The conversion from metoprolol tartrate to carvedilol should be done under close medical supervision, with regular monitoring of blood pressure, heart rate, and renal function 5, 6.
• Patients should be educated on the potential differences in side effects between carvedilol and metoprolol, such as dizziness and postural hypotension with carvedilol 2, 3.