Metoprolol (Lexi-Drugs)

ALERT: US Boxed Warning
  Ischemic heart disease:
Drug Shortages

One or more forms of this drug may be in short supply or unavailable. Refer to the following for additional information:

ASHP: http://www.ashp.org/menu/DrugShortages

Pronunciation

(me toe PROE lole)

Brand Names: US

Kapspargo Sprinkle; Lopressor; Toprol XL

Brand Names: Canada

AG-Metoprolol-L; APO-Metoprolol; APO-Metoprolol SR; APO-Metoprolol-Type L; Betaloc [DSC]; DOM-Metoprolol; DOM-Metoprolol-L; JAMP-Metoprolol-L; Lopresor; Lopresor SR; Metoprolol-100; Metoprolol-25; Metoprolol-50; Metoprolol-L; MYLAN-Metoprolol [DSC]; NTP-Metoprolol [DSC]; PMS-Metoprolol-B; PMS-Metoprolol-L; RIVA-Metoprolol-L; SANDOZ Metoprolol (Type L) [DSC]; Sandoz Metoprolol SR; TEVA-Metoprolol

Dosing: Adult

Angina: Note: For vasospastic angina, beta-blockers are not recommended; calcium channel blockers and nitrates are preferred in this situation. For nonvasospastic angina, guidelines recommend titrating dose to a resting heart rate of 55 to 60 beats per minute (ACCF/AHA [Fihn 2012]), while other experts recommend target 50 to 60 beats per minute and note that <50 beats per minute could be a reasonable goal for severe angina as long as there is no symptomatic bradycardia or heart block (Kannam 2018).

Immediate release (metoprolol tartrate): Oral: Initial: 50 mg twice daily; may increase dose at weekly intervals to desired effect; usual dosage range: 50 to 200 mg twice daily; maximum dose: 400 mg/day

Extended release (metoprolol succinate): Oral: Initial: 100 mg once daily; may increase dose at weekly intervals to desired effect; maximum dose: 400 mg/day

Note: For microvascular angina, some experts start with 50 mg/day (divided twice daily for the immediate-release formulation or once daily for the extended-release formulation) and increase to 100 to 200 mg/day as needed to control symptoms (Chaudhary 2018).

Atrial fibrillation/flutter (off-label use):

Acute ventricular rate control: IV: 2.5 to 5 mg over 2 minutes; repeat dose every 5 minutes as needed; maximum total dose: 15 mg). Note: Initiate cautiously in patients with concomitant heart failure. Avoid in patients with decompensated heart failure; electrical cardioversion preferred (AHA/ACC/HRS [January 2014]; AHA [Neumar 2010]).

Maintenance of ventricular rate control:

Immediate release (metoprolol tartrate): Oral: 25 to 100 mg twice daily (AHA/ACC/HRS [January 2014]). Note: More frequent dosing is appropriate in the acute setting while titrating to a maintenance dose.

Extended release (metoprolol succinate): Oral: 50 to 400 mg once daily (AHA/ACC/HRS [January 2014])

Atrial fibrillation prevention after cardiac surgery: Note: Initiate prior to surgery (preferentially at least 48 hours before) or postoperatively when hemodynamically stable. Continue therapy at least until the first postoperative visit in patients with no other indication for beta-blocker therapy (Lee 2018).

Immediate release (metoprolol tartrate): Oral: Initial: 25 to 50 mg twice daily; titrate based on daily evaluation of hemodynamic response to the maximally tolerated dose; maximum dose: 200 mg/day (Acikel 2008; Haghjoo 2007)

Extended release (metoprolol succinate): Oral: Initial: 50 mg once daily; titrate based on daily evaluation of hemodynamic response to the maximally tolerated dose; maximum dose: 200 mg/day (Ozaydin 2013)

Heart failure with reduced ejection fraction (HFrEF): Note: Initiate only in stable patients. In hospitalized patients, volume status should be optimized and IV diuretics, vasodilators, and inotropic agents successfully discontinued. Use caution when initiating in patients with NYHA class IV symptoms or recent HF exacerbation (particularly in those who required inotropes during their hospital course) (ACCF/AHA [Yancy 2013]; Colucci 2018).

Extended release (metoprolol succinate): Oral: Initial: 12.5 to 25 mg once daily; up-titrate gradually (eg, doubling the dose every 2 or more weeks) to the maximum tolerated dose while monitoring for signs and symptoms of HF; maximum dose: 200 mg/day (ACCF/AHA [Yancy 2013]; ACC/AHA/HFSA [Yancy 2017]; MERIT-HF Study Group 1999)

Hypertension (alternative agent): Note: Not recommended in the absence of specific comorbidities (eg, ischemic heart disease, HFrEF, arrhythmia) (ACC/AHA [Whelton 2017]).

Immediate release (metoprolol tartrate): Oral: Initial: 50 mg twice daily; titrate at weekly (or longer) intervals as needed based on patient response; maximum dose: 400 mg/day; usual dosage range: 100 to 200 mg/day in 2 divided doses (ACC/AHA [Whelton 2017])

Extended release (metoprolol succinate): Oral: Initial: 25 to 100 mg once daily; titrate at weekly (or longer) intervals as needed based on patient response; maximum dose: 400 mg/day; usual dosage range: 50 to 200 mg once daily (ACC/AHA [Whelton 2017])

Migraine prophylaxis (off-label use): Immediate release (metoprolol tartrate): Oral: Initial: 25 mg twice daily; titrate slowly (eg, every 1 to 2 weeks) based on patient response and tolerability up to 200 mg/day in divided doses; maintain for at least 3 months before considering treatment failure (Bajwa 2018; Diener 2001; Pringsheim 2012; Schellenberg 2008).

Myocardial infarction, early treatment and secondary prevention: Note: An oral beta-blocker is recommended within the first 24 hours if there are no contraindications. Do not initiate metoprolol in patients with signs of heart failure, a low output state, increased risk of cardiogenic shock, or other contraindications for beta-blockade (eg, second- or third-degree heart block) (ACCF/AHA [O’Gara 2013]). Patients who did not receive a beta-blocker within 24 hours of myocardial infarction because of early contraindications should be subsequently reevaluated for secondary prevention. The optimal duration of therapy is unknown; some experts treat for a minimum of 3 years and use a longer duration for patients with high-risk features (eg, cardiogenic shock, heart failure, chronic kidney disease) at initial presentation (Rosenson 2018).

IV: Note: Small doses of IV metoprolol at the time of presentation may be considered for ST-elevation myocardial infarction (STEMI) patients with hypertension or ongoing ischemia if no contraindications exist. Initial: 5 mg; repeat dose every 5 minutes for up to 3 doses as needed based on heart rate and blood pressure; maximum total dose: 15 mg; begin oral therapy 15 to 30 minutes after the last IV dose (ACCF/AHA [O’Gara 2013]; Chen 2005; Rosenson 2018).

Oral:

Immediate release (metoprolol tartrate): Initial: 25 to 50 mg every 6 to 12 hours in the acute setting; some experts suggest a lower starting dose of 12.5 mg every 6 to 12 hours when concern for adverse effects remain; for outpatients, transition to twice-daily dosing of metoprolol tartrate (immediate release) or to daily metoprolol succinate (extended release); titrate dose based on heart rate and blood pressure as tolerated up to a maximum dose of 200 mg/day (ACCF/AHA [O’Gara 2013]; Rosenson 2018; Simons 2018).

Extended release (metoprolol succinate): Initial: 25 to 50 mg once daily is also recommended by some experts; titrate dose based on heart rate and blood pressure as tolerated up to 200 mg once daily (Rosenson 2018; Simons 2018).

Supraventricular tachycardia (eg, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal atrial tachycardia) (off-label use):

Acute treatment: IV: 2.5 to 5 mg over 2 minutes; repeat dose every 5 minutes as needed; maximum total dose: 15 mg. Note: Initiate cautiously in patients with concomitant heart failure. Avoid in patients with decompensated heart failure; electrical cardioversion preferred (ACC/AHA/HRS [Page 2016]; AHA [Neumar 2010]).

Maintenance therapy:

Immediate release (metoprolol tartrate): Oral: Initial: 25 mg twice daily; maximum dose: 400 mg/day (ACC/AHA/HRS [Page 2016])

Extended release (metoprolol succinate): Oral: Initial: 50 mg once daily; maximum dose: 400 mg/day (ACC/AHA/HRS [Page 2016])

Thyrotoxicosis (off-label use): Immediate release (metoprolol tartrate): Oral: 25 to 50 mg every 8 to 12 hours; may also consider administering an equivalent dose of the once-daily extended-release formulation (metoprolol succinate) (Ross 2016).

Ventricular arrhythmias (off-label use):

Sustained ventricular tachycardia (VT), incessant VT, or electric storm (hemodynamically stable): Note: Beta-blockers are generally administered in addition to an antiarrhythmic drug (eg, amiodarone) for these indications. A beta-blocker is also used to reduce shocks in patients who receive an implantable cardioverter defibrillator for these indications (AHA/ACC/HRS [Al-Khatib 2017]); propranolol may be the preferred beta-blocker in these situations (Chatzidou 2018).

Acute ventricular tachycardia (eg, sustained VT):IV: 5 mg every 5 minutes up to 3 doses (AHA/ACC/HRS [Al-Khatib 2017])

Prevention of ventricular arrhythmias:

Immediate release (metoprolol tartrate): Oral: Initial: 12.5 to 25 mg twice daily; increase as needed based on patient response; maximum dose: 200 mg/day in 2 or 3 divided doses (Kettering 2002; Kuck 2000; Seidl 1998)

Extended release (metoprolol succinate): Oral: 25 to 100 mg 1 to 2 times daily (AHA/ACC/HRS [Al-Khatib 2017])

Nonsustained VT or ventricular premature beats, symptomatic: Note: Unless there are other indications for a beta-blocker (eg, prior MI or heart failure), use the lowest dose that alleviates symptoms.

Immediate release (metoprolol tartrate): Oral: 50 to 200 mg/day in 2 or 3 divided doses (Zimetbaum 2018)

Extended release (metoprolol succinate): Oral: 25 to 100 mg 1 to 2 times daily (AHA/ACC/HRS [Al-Khatib 2017])

Switching dosage forms:

Switching from immediate release (metoprolol tartrate) to extended release (metoprolol succinate): The same total daily dose of metoprolol should be used. Metoprolol tartrate is typically administered in 2 to 3 divided daily doses and metoprolol succinate is administered once daily.

Switching between oral and intravenous dosage forms: In most cases, equivalent beta-blocking effect is achieved when a 2.5:1 (Oral:IV) ratio is used. However, in one bioavailability study of healthy volunteers (N=5), the range of Oral:IV conversion ratios was approximately 2:1 to 5:1 (Regrdh 1974). Therefore, patient variability may exist and a specific ratio may not apply to all patients, especially if comorbid conditions are present. The estimated equivalent IV total daily dose should be divided into 4 equal doses. For example, if a patient is receiving a chronic oral dose of metoprolol tartrate 25 mg twice daily (total daily dose of 50 mg), this could translate to a range of 2.5 mg IV every 6 hours (based on a 5:1 ratio) to 5 mg IV every 6 hours (based on a 2.5:1 ratio). Recognizing that patients receiving larger chronic oral doses should not automatically be converted to a large IV dose, consideration should be given to further reducing the initial IV dose and basing subsequent doses on the clinical response (Huckleberry 2003).

Dosing: Geriatric

Refer to adult dosing. In the management of hypertension, consider lower initial doses and titrate to response (Aronow 2011).

Dosing: Renal Impairment: Adult

 No dosage adjustment necessary.

Dosing: Hepatic Impairment: Adult

There are no specific dosage adjustments provided in the manufacturer’s labeling. Consider initiating with reduced doses and gradual dosage titration due to extensive hepatic metabolism.

Dosing: Pediatric

Note: Dose should be individualized based on patient response.

Heart failure (dilated cardiomyopathy): Limited data available: Children and Adolescents: Oral: Immediate release (metoprolol tartrate): Initial: 0.1 to 0.2 mg/kg/dose twice daily, may increase slowly (usually every 2 weeks) as needed up to 1 mg/kg/day; maximum daily dose: 2 mg/kg/day or 200 mg/day, whichever is less (Kliegman 2011; Park 2014; Shaddy 1999). Dosing based on a multicenter, open-label trial in 15 pediatric patients (age range: 2.5 to 15 years, mean: 8.6 ± 1.3 years) with dilated cardiomyopathy with heart failure that failed to show improvement in left ventricular function on conventional therapy; after 23 months of metoprolol, significant increases in ejection fraction (mean: 41.1%) and fractional shortening (mean: 23.3%) were observed; the reported mean maximum daily dose was 1.1 ± 0.1 mg/kg/day (range: 0.5 to 2.3 mg/kg/day) (Shaddy 1999).

Hypertension: Note: Guidelines do not recommend beta-blockers as initial therapy in pediatric patients; beta-blockers should be reserved for use in patients who have contraindications to preferred agents or after ≥2 preferred agents have failed in patients with hypertension and chronic kidney disease, proteinuria, or diabetes mellitus (AAP [Flynn 2017]).

Immediate-release tablets (metoprolol tartrate): Children and Adolescents ≤17 years: Oral: Initial: 0.5 to 1 mg/kg/dose (maximum initial dose: 25 mg/dose) twice daily; adjust dose based on patient response; maximum daily dose: 6 mg/kg/day or 200 mg/day, whichever is less (NHBPEP [Falkner 2004]; NHLBI [Kavey 2011])

Extended-release sprinkle capsules or tablets (metoprolol succinate): Children ≥6 years and Adolescents: Oral: Initial: 1 mg/kg/dose once daily (maximum initial dose: 50 mg/dose); adjust dose based on patient response; maximum daily dose: 2 mg/kg/day or 200 mg/day, whichever is less; higher doses have not been studied.

Syncope, vagal: Limited data available: Children ≥7 years and Adolescents:

Tilt-table test: IV: 0.1 to 0.2 mg/kg; maximum dose: 10 mg/dose (Muller 1993, O’Marcaigh 1994)

Chronic treatment: Oral: Immediate release (metoprolol tartrate): 0.5 to 1 mg/kg/dose two times daily; maximum daily dose: 6 mg/kg/day (Kliegman 2011; Muller 1993; O’Marcaigh 1994). Dosing based on two studies: In one study, oral metoprolol was initiated at doses of 0.8 to 2.8 mg/kg/day in 15 patients (8 to 20 years of age) after showing response to tilt-table testing. During follow up, a total of 6 patients discontinued therapy due to recurrent syncope or adverse events including irritability/moodiness, severe depression, and severe nausea (dose ranged in this group from 1.6 to 2.8 mg/kg/day) (Muller 1993); in another study, oral doses of 1 to 2 mg/kg/day, rounded to the nearest 25 mg/day and divided into 2 doses daily were used in 19 patients (7 to 18 years of age) with unexplained syncope; the mean effective dose was 1.5 mg/kg/day (O’Marcaigh 1994).

Dosing: Renal Impairment: Pediatric

Children and Adolescents: No dosage adjustment necessary

Dosing: Hepatic Impairment: Pediatric

Children and Adolescents: There are no specific dosage adjustments provided in the manufacturer’s labeling. Consider initiating with reduced doses and gradual dosage titration due to extensive hepatic metabolism.

Use: Labeled Indications

Angina: Long-term treatment of angina pectoris.

Heart failure with reduced ejection fraction (HFrEF) (ER oral formulation): Treatment of stable, symptomatic (NYHA class II or III) heart failure of ischemic, hypertensive, or cardiomyopathic origin to reduce the rate of mortality plus hospitalization in patients already receiving ACE inhibitors, diuretics, and/or digoxin.

Hypertension: Management of hypertension. Note: Beta-blockers are not recommended as first-line therapy (ACC/AHA [Whelton 2017]).

Myocardial infarction: Treatment of hemodynamically stable acute myocardial infarction (MI) to reduce cardiovascular mortality (injection to be used in combination with metoprolol oral maintenance therapy).

Use: Off-Label: Adult

  Atrial fibrillation/flutter (rate control)Level of Evidence [G]

Based on the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines for the management of patients with atrial fibrillation, the use of beta-blockers, including metoprolol, for ventricular rate control in patients with paroxysmal, persistent, or permanent atrial fibrillation is effective and recommended.

  Atrial fibrillation prevention after cardiac surgeryLevel of Evidence [G]

Based on the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guideline for coronary artery bypass graft surgery, beta-blockers are recommended to help prevent postoperative atrial fibrillation.

  Hypertrophic cardiomyopathyLevel of Evidence [G]

Based on the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guideline for the diagnosis and treatment of hypertrophic cardiomyopathy, a beta blocker (eg, metoprolol) is an effective and recommended agent for the treatment of symptoms (eg, angina, dyspnea) in patients with obstructive or nonobstructive hypertrophic cardiomyopathy.

  Marfan syndrome with aortic aneurysmLevel of Evidence [G]

Based on the American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery (ACCF/AHA/AATS) guideline for the diagnosis and management of patients with thoracic aortic disease, a beta blocker (eg, metoprolol) is an effective and recommended agent to reduce the rate of aortic dilatation in patients with Marfan syndrome and aortic aneurysm, unless a contraindication exists.

  Migraine prophylaxisLevel of Evidence [B, G]

Data from small, randomized, active-controlled trials support the use of metoprolol for prevention of migraines Ref.

Based on evidence-based guidelines for pharmacologic treatment for episodic migraine prevention in adults from the American Academy of Neurology and the American Headache Society, metoprolol is effective for migraine prevention in adults.

  Supraventricular tachycardia (eg, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal atrial tachycardia)Level of Evidence [G]

Based on the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) guidelines for the management of adult patients with supraventricular tachycardia, the use of an oral or intravenous beta-blocker, including metoprolol, is effective and recommended for a variety of symptomatic supraventricular tachycardias (atrioventricular nodal reentrant tachycardia [AVNRT], atrioventricular reentrant tachycardia [AVRT], focal atrial tachycardia [AT], and multifocal atrial tachycardia [MAT]). In patients without pre-excitation, intravenous metoprolol is recommended for acute treatment in hemodynamically stable patients and oral metoprolol is recommended for ongoing management of symptomatic supraventricular tachycardias in patients who are not candidates for, or prefer not to undergo, catheter ablation. Intravenous or oral metoprolol may be useful for rate control in the acute treatment or ongoing management of hemodynamically stable patients with atrial flutter.

  ThyrotoxicosisLevel of Evidence [G]

Based on the American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis, beta-blockers, including metoprolol, are effective and recommended in the treatment of symptomatic thyrotoxicosis. Beta-blockers should also be considered in asymptomatic patients who are at increased risk of complications due to worsening hyperthyroidism.

  Ventricular arrhythmiasLevel of Evidence [G]

Level of Evidence Definitions
  Level of Evidence Scale
Clinical Practice Guidelines

Advanced Cardiac Life Support (ACLS)/Emergency Cardiovascular Care (ECC):

AHA, “2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” October 2015

AHA, “2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” November 2010

Arrhythmias:

AHA/ACC/HRS, “2017 AHA/ACC/HRS Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death,” October 2017

AATS, “2014 AATS Guidelines for the Prevention and Management of Perioperative Atrial Fibrillation and Flutter for Thoracic Surgical Procedures,” June 2014

ACC/AHA/HRS, “Guideline for the Management of Adult Patients with Supraventricular Tachycardia,” 2015

AHA/ACC/HRS, “2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation,” March 2014

Canadian Cardiovascular Society, “2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation,” 2016

Coronary Artery Bypass Graft Surgery:

“2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery,” November 2011

Heart Failure:

ACC/AHA/HFSA “Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure,” August 2017

ACC/AHA/HFSA, “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure,” May 2016

ACCF/AHA, “2013 ACCF/AHA Guideline for the Management of Heart Failure,” June 2013

Hypertension:

“2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults,” November 2017.

AHA/ACC/ASH, “Treatment of Hypertension in Patients with Coronary Artery Disease: A Scientific Statement by the American Heart Association, American College of Cardiology and American Society of Hypertension,” May 2015

“ACCF/AHA Expert Consensus Document on Hypertension in the Elderly,” 2011

AHA/ACC/CDC, “AHA/ACC/CDC Science Advisory: An Effective Approach to High Blood Pressure Control” November 2013

ASH/ISH “Clinical Practice Guidelines for the Management of Hypertension in the Community: A Statement by the American Society of Hypertension and the International Society of Hypertension,” January 2014

Eighth Joint National Committee (JNC 8), “2014 Evidence-based Guideline for the Management of High Blood Pressure in Adults,” December 2013

“National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents,” May 2005

Hyperthyroidism:

ATA, “Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis,” 2016

Ischemic Heart Disease:

ACC/AHA/AATS/PCNA/SCAI/STS, “2014 Focused Update of the Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease,” July 2014

ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, “2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease,” November 2012

AHA/ACC, “2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes,” September 2014

ACCF/AHA, “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction,” December 2012

Migraine Prophylaxis:

Neurology, “Evidence-Based Guideline Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults,” April 2012

Peripheral Arterial Disease:

“ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease,” March 2006

Prevention:

“AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update,” November 2011

Surgery:

ACC/AHA, “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery,” August 2014

Valvular Heart Disease:

AHA/ACC, “2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease,” March 2014

Administration: IV

When administered acutely for cardiac treatment, monitor ECG and blood pressure. Administer by IV bolus. Some centers may administer by slow infusion (ie, 5 to 10 mg of metoprolol in 50 mL of fluid) over ~30 to 60 minutes during less urgent situations (eg, substitution for oral metoprolol).

Administration: Injectable Detail

pH: 7.5

Administration: Oral

Immediate release (metoprolol tartrate): Administer with or immediately following meals.

Extended release (metoprolol succinate): According to the manufacturer, it is preferable to administer with or immediately following meals; however, may also administer without regard to meals (Tangeman 2003; van den Berg 1990; Wikstrand 2003). May divide tablets in half; do not crush or chew.

Sprinkle capsule: May be swallowed whole or the capsule may be opened and contents sprinkled on a small amount (1 teaspoonful) of soft food (eg, applesauce, pudding, or yogurt) to be used within 60 minutes (do not store for future use).

Nasogastric tube administration: Open capsule and add contents to an all plastic oral tip syringe; add 15 mL of water. Gently shake the syringe for ~10 seconds. Immediately deliver mixture through a ≥12 French nasogastric tube. No granules should remain in the syringe; rinse syringe with additional water if necessary.

Administration: Pediatric

Oral:

Immediate release (metoprolol tartrate): Tablets: Administer with food or immediately after meals; swallow whole with a glass of water.

Extended release (metoprolol succinate):

Sprinkle capsules: Administer without regard to meals; may be swallowed whole or the capsule may be opened and the contents sprinkled on small amount (1 teaspoonful) of soft food (eg, pudding, applesauce, yogurt) and used within 60 minutes of preparation; do not store drug-food mixture for later use.

Nasogastric tube administration: Open capsule and add contents to an all plastic oral syringe and add 15 mL of water; gently shake syringe for ~10 seconds to disperse granules. Administer immediately through ≥12-french nasogastric tube. No granules should remain in syringe; rinse syringe with additional water if necessary.

Tablets: May be administered without regard to meals; Toprol-XL tablets are scored and may be divided; do not chew or crush the half or whole tablets; swallow whole. Do not chew, crush, or break generic nonscored extended-release tablets; swallow whole.

Parenteral: IV dose is much smaller than oral dose. When administered acutely for cardiac treatment, monitor ECG and blood pressure

Children ≥7 years and Adolescents: Limited data available; dose was administered over 10 minutes in one study (Muller 1993)

Adults: May administer undiluted by rapid infusion (IV push) over 1 minute. May also be administered by slow infusion (ie, 5 to 10 mg of metoprolol in 50 mL of fluid) over ~30 to 60 minutes during less urgent situations (eg, substitution for oral metoprolol).

Storage/Stability

Injection: Store at 20°C to 25°C (68°F to 77°F). Do not freeze; protect from light.

Sprinkle capsules: Store at 20°C to 25°C (68°F to 77°F).

Tablet: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from moisture.

Compatibility

See Trissel’s IV Compatibility Database

Extemporaneously Prepared

10 mg/mL Oral Suspension (ASHP Standard Concentration) (ASHP 2017)

A 10 mg/mL oral suspension may be made with metoprolol tartrate tablets and one of three different vehicles (cherry syrup; a 1:1 mixture of Ora-Sweet and Ora-Plus; or a 1:1 mixture of Ora-Sweet SF and Ora-Plus). Crush twelve 100 mg tablets in a mortar and reduce to a fine powder. Add 20 mL of the chosen vehicle and mix to a uniform paste; mix while adding the vehicle in incremental proportions to almost 120 mL; transfer to a calibrated bottle, rinse mortar with vehicle, and add quantity of vehicle sufficient to make 120 mL. Label “shake well” and “protect from light”. Stable for 60 days.

Allen LV Jr and Erickson MA 3rd, “Stability of Labetalol Hydrochloride, Metoprolol Tartrate, Verapamil Hydrochloride, and Spironolactone With Hydrochlorothiazide in Extemporaneously Compounded Oral Liquids,” Am J Health Syst Pharm, 1996, 53(19):2304-9.[PubMed 8893069]

Medication Patient Education with HCAHPS Considerations

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience diarrhea, loss of strength and energy, nausea, or vomiting. Have patient report immediately to prescriber depression, severe dizziness, passing out, angina, abnormal heartbeat, bradycardia, shortness of breath, excessive weight gain, or swelling of arms or legs(HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Medication Safety Issues
  Sound-alike/look-alike issues:
  High alert medication:
  Administration issues:
Contraindications

Hypersensitivity to metoprolol, any component of the formulation, or other beta-blockers; second- or third-degree heart block

Note: Additional contraindications are formulation and/or indication specific.

Immediate-release tablets/injectable formulation:

Hypertension and angina (oral only): Sinus bradycardia; cardiogenic shock; overt heart failure; sick sinus syndrome; severe peripheral arterial circulatory disorders

Myocardial infarction (oral and injection): Severe sinus bradycardia (heart rate <45 beats/minute); significant first-degree heart block (P-R interval ≥0.24 seconds); systolic blood pressure <100 mm Hg; moderate to severe cardiac failure

Extended-release formulation: Severe bradycardia, cardiogenic shock; decompensated heart failure; sick sinus syndrome (except in patients with a functioning artificial pacemaker)

Documentation of allergenic cross-reactivity for beta-blockers is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Canadian labeling: Additional contraindications (not in US labeling): Cor pulmonale; untreated pheochromocytoma; asthma and other obstructive respiratory disease (injection only); concomitant use with anesthesia agents that cause myocardial depression

Warnings/Precautions

Concerns related to adverse events:

• Anaphylactic reactions: Use caution with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to repeated allergen challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects.

• Atrioventricular (AV) block: Metoprolol commonly produces mild first-degree heart block. Metoprolol may also produce severe first-, second-, or third-degree heart block. Patients with acute myocardial infarction (especially right ventricular myocardial infarction) have a high risk of developing heart block of varying degrees. If severe heart block occurs, metoprolol should be discontinued and measures to increase heart rate should be employed.

• Bradycardia: Bradycardia, including sinus pause, heart block, and cardiac arrest, may occur. Patients with first-degree AV block, sinus node dysfunction, or conduction disorders may be at increased risk. Monitor heart rate and rhythm; if severe bradycardia occurs, reduce dose or discontinue therapy.

• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery, driving).

• Hypotension: Symptomatic hypotension may occur with use.

Disease-related concerns:

• Bronchospastic disease: In general, patients with bronchospastic disease should not receive beta-blockers; however, metoprolol, with B1 selectivity, has been used cautiously with close monitoring.

• Conduction abnormality: Consider preexisting conditions such as sick sinus syndrome before initiating.

• Diabetes: Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.

• Heart failure: Use with caution in patients with compensated heart failure; monitor for a worsening of heart failure (only the ER formulation is indicated for use in heart failure). May need to increase diuretics and wait until clinically stable to advance dose to target.

• Hepatic impairment: Use with caution in patients with hepatic impairment.

• Myasthenia gravis: Use beta-blockers with caution in patients with myasthenia gravis.

• Peripheral vascular disease (PVD) and Raynaud disease: May precipitate or aggravate symptoms of arterial insufficiency in patients with PVD and Raynaud disease. Use with caution and monitor for progression of arterial obstruction.

• Pheochromocytoma (untreated): Adequate alpha-blockade is required prior to use of any beta-blocker.

• Prinzmetal variant angina: Beta-blockers without alpha1-adrenergic receptor blocking activity should be avoided in patients with Prinzmetal variant angina because unopposed alpha1-adrenergic receptors mediate coronary vasoconstriction and can worsen anginal symptoms (Mayer 1998).

• Psoriasis: Beta-blocker use has been associated with induction or exacerbation of psoriasis, but cause and effect have not been firmly established.

• Supraventricular tachycardia (SVT): If antidromic atrioventricular reentrant tachycardia (AVRT) or pre-excited atrial fibrillation is suspected, avoid AV node-specific blocking drugs (eg, adenosine, diltiazem, verapamil, digoxin, beta-blockers). For these types of SVT enhanced antegrade conduction from atria to ventricles may occur through an accessory pathway leading to ventricular arrhythmias if the AV node is blocked. It is safe to use AV node-specific blocking drugs for orthodromic AVRT because antegrade conduction occurs through the AV node and only retrograde conduction (from ventricles to atria) occurs through the accessory pathway.

• Thyroid disease: May mask signs of hyperthyroidism (eg, tachycardia). If hyperthyroidism is suspected, carefully manage and monitor; abrupt withdrawal may exacerbate symptoms of hyperthyroidism or precipitate thyroid storm. Alterations in thyroid function tests may be observed.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Dosage form specific issues:

• Switching dosage forms: The conversion ratio for immediate release (metoprolol tartrate) and extended release (metoprolol succinate) is 1:1, therefore the same total daily dose of metoprolol should be used when switching formulations. However, metoprolol tartrate is typically administered in 2 to 3 divided daily doses and metoprolol succinate is administered once daily.

Special populations:

• Elderly: Bradycardia may be observed more frequently in elderly patients (>65 years of age); dosage reductions may be necessary.

Other warnings/precautions:

• Abrupt withdrawal: [US Boxed Warning]: Beta-blocker therapy should not be withdrawn abruptly (particularly in patients with CAD), but gradually tapered over 1 to 2 weeks to avoid acute tachycardia, hypertension, and/or ischemia. Severe exacerbation of angina, ventricular arrhythmias, and myocardial infarction (MI) have been reported following abrupt withdrawal of beta-blocker therapy. Temporary but prompt resumption of beta-blocker therapy may be indicated with worsening of angina or acute coronary insufficiency.

• Major surgery: Chronic beta-blocker therapy should not be routinely withdrawn prior to major surgery.

Geriatric Considerations

Due to alterations in the beta-adrenergic autonomic nervous system, beta-adrenergic blockade may result in less hemodynamic response than seen in younger adults. Studies indicate that despite decreased sensitivity to the chronotropic effects of beta-blockade with age, there appears to be an increased myocardial sensitivity to the negative inotropic effect during stress (ie, exercise). Controlled trials have shown the overall response rate for propranolol to be only 20% to 50% in the elderly populations. Therefore, all beta-adrenergic blocking drugs may result in a decreased response as compared to younger adults.

The AHA/ACC/ASH 2015 scientific statement on the treatment of hypertension in patients with CAD warns to use caution to avoid decreases in DBP <60 mm Hg especially in patients >60 years of age since reduced coronary perfusion may occur. When lowering SBP in older hypertensive patients with wide pulse pressures, very low DBP values (<60 mm Hg) may result. In patients with obstructive CAD, clinicians should lower blood pressure slowly and carefully monitor for any untoward signs or symptoms, especially those resulting from myocardial ischemia and worsening heart failure (AHA/ACC/ASH [Rosendorff 2015]).

Warnings: Additional Pediatric Considerations

Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Shehab 2009).

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies. Metoprolol and the metabolite alpha-hydroxymetoprolol cross the placenta and can be detected in cord blood (Lindeberg 1987; Ryu 2016).

Adverse events, such as fetal/neonatal bradycardia, hypoglycemia, and reduced birth weight, have been observed following in utero exposure to beta-blockers as a class. Adequate facilities for monitoring infants at birth is generally recommended. The pharmacokinetics of metoprolol may be changed during pregnancy; the degree of changes may be dependent upon maternal CYP2D6 genotype (Ryu 2016).

Untreated chronic maternal hypertension and preeclampsia are also associated with adverse events in the fetus, infant, and mother (ACOG 2015; Magee 2014). Recommendations for the treatment of hypertension in pregnancy vary by guideline, but use of metoprolol may be considered (ESC [Regitz-Zagrosek 2011]; Magee 2014). Heart failure, peripartum cardiomyopathy, and valvular heart disease may cause severe complications in pregnant women; metoprolol is recommended when use of a beta-blocker is indicated (AHA/ACC [Nishimura 2014]; ESC [Regitz-Zagrosek 2011]; Sliwa 2010). Use of metoprolol may be considered for some arrhythmias, including SVT, when a beta-blocker is needed (ACC/AHA/HRS [Page 2016]; ESC [Regitz-Zagrosek 2011]). Use of metoprolol may be considered if migraine prophylaxis is needed in a pregnant woman (Pringsheim 2012).

Breast-Feeding Considerations

Metoprolol is present in breast milk.

The relative infant dose (RID) of metoprolol is 1.7% to 10% when calculated using the highest breast milk concentration located and compared to an infant therapeutic dose of 1 to 6 mg/kg/day.

In general, breastfeeding is considered acceptable when the RID is <10% (Anderson 2016; Ito 2000).

The RID of metoprolol was calculated using a milk concentration of 690 ng/mL, providing an estimated daily infant dose via breast milk of 0.1 mg/kg/day. This milk concentration was obtained following maternal administration of oral metoprolol 100 mg twice daily (Liedholm 1981). A case report also notes the presence of the α-OH-metoprolol metabolite in breast milk (Grundman 2011). Metoprolol is measurable in the serum of some breastfed infants (Sandström 1983). Adverse events were not reported in six infants exposed to metoprolol via breast milk (Ho 1999).

Use of antihypertensive agents with lower concentrations in breast milk may be preferred in women who wish to breastfeed (ACOG 2013). Breastfeeding is not recommended for women with heart failure related to PPCM due to the high metabolic demands of lactation and breastfeeding (ESC [Regitz-Zagrosek 2011]; Sliwa 2010).

Lexicomp Pregnancy & Lactation, In-Depth
Briggs’ Drugs in Pregnancy & Lactation
Adverse Reactions

Frequency not always defined.

Cardiovascular: Hypotension (1% to 27%), bradycardia (2% to 16%), first degree atrioventricular block (5%), arterial insufficiency (usually Raynaud type: 1%), cardiac failure (1%), cerebrovascular accident (1%), cold extremities (1%), palpitations (1%), peripheral edema (1%), claudication

Central nervous system: Dizziness (2% to 10%), fatigue (1% to 10%), depression (>2% to 5%), vertigo (≤2%), confusion, disturbed sleep, hallucination, headache, insomnia, nightmares, temporary amnesia

Dermatology: Pruritus (5%), skin rash (>2% to 5%), exacerbation of psoriasis, skin photosensitivity

Endocrine & metabolic: Decreased libido, unstable diabetes

Gastrointestinal: Diarrhea (>2% to 5%), constipation (1%), flatulence (1%), heartburn (1%), stomach pain (1%), xerostomia (1%), nausea (≤1%), vomiting

Neuromuscular & skeletal: Musculoskeletal pain

Ophthalmic: Blurred vision, visual disturbance

Otic: Tinnitus

Respiratory: Dyspnea (≤3%), bronchospasm (1%), wheezing (1%), rhinitis

Miscellaneous: Accidental injury (1%)

<1%, postmarketing and/or case reports: Abdominal pain, agranulocytosis, alopecia (reversible), anxiety, arthralgia, arthritis, chest pain, decreased HDL cholesterol, diaphoresis, drowsiness, dry eye syndrome, gangrene of skin or other tissue, hepatic insufficiency, hepatitis, impotence, increased lactate dehydrogenase, increased serum alkaline phosphatase, increased serum transaminases, increased serum triglycerides, jaundice, nervousness, paresthesia, Peyronie’s disease, retroperitoneal fibrosis, syncope, taste disorder, weight gain

Allergy and Idiosyncratic Reactions
Toxicology
Metabolism/Transport Effects

Substrate of CYP2C19 (minor), CYP2D6 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions 

Abiraterone Acetate: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity. Risk D: Consider therapy modification

Acetylcholinesterase Inhibitors: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy

Ajmaline: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Alpha1-Blockers: Beta-Blockers may enhance the orthostatic hypotensive effect of Alpha1-Blockers. The risk associated with ophthalmic products is probably less than systemic products. Risk C: Monitor therapy

Alpha2-Agonists: May enhance the AV-blocking effect of Beta-Blockers. Sinus node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound hypertensive effect of Alpha2-Agonists. This effect can occur when the Alpha2-Agonist is abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists are unavailable.Exceptions: Apraclonidine. Risk D: Consider therapy modification

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Risk D: Consider therapy modification

Aminoquinolines (Antimalarial): May decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy

Amiodarone: May enhance the bradycardic effect of Beta-Blockers. Possibly to the point of cardiac arrest. Amiodarone may increase the serum concentration of Beta-Blockers. Risk C: Monitor therapy

Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Antipsychotic Agents (Phenothiazines): May enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents (Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]).Risk C: Monitor therapy

Asunaprevir: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk D: Consider therapy modification

Barbiturates: May decrease the serum concentration of Beta-Blockers. Risk C: Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Beta2-Agonists: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Risk C: Monitor therapy

Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Risk C: Monitor therapy

Bretylium: May enhance the bradycardic effect of Bradycardia-Causing Agents. Bretylium may also enhance atrioventricular (AV) blockade in patients receiving AV blocking agents. Risk C: Monitor therapy

Brigatinib: May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Bromperidol: Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. Risk X: Avoid combination

Bupivacaine: Beta-Blockers may increase the serum concentration of Bupivacaine. Risk C: Monitor therapy

Calcium Channel Blockers (Nondihydropyridine): May enhance the hypotensive effect of Beta-Blockers. Bradycardia and signs of heart failure have also been reported. Calcium Channel Blockers (Nondihydropyridine) may increase the serum concentration of Beta-Blockers. Exceptions: Bepridil. Risk C: Monitor therapy

Cardiac Glycosides: Beta-Blockers may enhance the bradycardic effect of Cardiac Glycosides. Risk C: Monitor therapy

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Exceptions are discussed in separate monographs. Risk D: Consider therapy modification

Cholinergic Agonists: Beta-Blockers may enhance the adverse/toxic effect of Cholinergic Agonists. Of particular concern are the potential for cardiac conduction abnormalities and bronchoconstriction. Management: Administer these agents in combination with caution, and monitor for conduction disturbances. Avoid methacholine with any beta blocker due to the potential for additive bronchoconstriction. Risk C: Monitor therapy

CloBAZam: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Cobicistat: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

CYP2D6 Inhibitors (Moderate): May increase the serum concentration of Metoprolol. Risk C: Monitor therapy

CYP2D6 Inhibitors (Strong): May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors). Risk D: Consider therapy modification

Dacomitinib: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of dacomitinib with CYP2D6 subtrates that have a narrow therapeutic index. Risk D: Consider therapy modification

Darunavir: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Dexmethylphenidate: May diminish the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Dipyridamole: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy

Disopyramide: May enhance the bradycardic effect of Beta-Blockers. Beta-Blockers may enhance the negative inotropic effect of Disopyramide. Risk C: Monitor therapy

Dronedarone: May enhance the bradycardic effect of Beta-Blockers. Dronedarone may increase the serum concentration of Beta-Blockers. This likely applies only to those agents that are metabolized by CYP2D6. Management: Use lower initial beta-blocker doses; adequate tolerance of the combination, based on ECG findings, should be confirmed prior to any increase in beta-blocker dose. Risk D: Consider therapy modification

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

EPINEPHrine (Nasal): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of EPINEPHrine (Nasal). Risk C: Monitor therapy

EPINEPHrine (Oral Inhalation): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of EPINEPHrine (Oral Inhalation). Risk C: Monitor therapy

Epinephrine (Racemic): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of Epinephrine (Racemic). Risk C: Monitor therapy

EPINEPHrine (Systemic): Beta-Blockers (Beta1 Selective) may diminish the therapeutic effect of EPINEPHrine (Systemic). Risk C: Monitor therapy

Ergot Derivatives: Beta-Blockers may enhance the vasoconstricting effect of Ergot Derivatives. Exceptions: Nicergoline. Risk D: Consider therapy modification

Fingolimod: Beta-Blockers may enhance the bradycardic effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and beta-blockers if possible. If coadministration is necessary, patients should have overnight continuous ECG monitoring conducted after the first dose of fingolimod. Monitor patients for bradycardia. Risk D: Consider therapy modification

Floctafenine: May enhance the adverse/toxic effect of Beta-Blockers. Risk X: Avoid combination

Grass Pollen Allergen Extract (5 Grass Extract): Beta-Blockers may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). More specifically, Beta-Blockers may inhibit the ability to effectively treat severe allergic reactions to Grass Pollen Allergen Extract (5 Grass Extract) with epinephrine. Some other effects of epinephrine may be unaffected or even enhanced (e.g., vasoconstriction) during treatment with Beta-Blockers. Risk D: Consider therapy modification

Herbs (Hypertensive Properties): May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Imatinib: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Insulins: Beta-Blockers may enhance the hypoglycemic effect of Insulins. Risk C: Monitor therapy

Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Risk C: Monitor therapy

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Risk C: Monitor therapy

Lercanidipine: May enhance the hypotensive effect of Metoprolol. Metoprolol may decrease the serum concentration of Lercanidipine. Risk C: Monitor therapy

Levodopa-Containing Products: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products. Risk C: Monitor therapy

Lidocaine (Systemic): Beta-Blockers may increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy

Lidocaine (Topical): Beta-Blockers may increase the serum concentration of Lidocaine (Topical). Risk C: Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Lumefantrine: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Mepivacaine: Beta-Blockers may increase the serum concentration of Mepivacaine. Risk C: Monitor therapy

Methacholine: Beta-Blockers may enhance the adverse/toxic effect of Methacholine. Risk X: Avoid combination

Methoxyflurane: May enhance the hypotensive effect of Beta-Blockers. Risk C: Monitor therapy

Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Mirabegron: May diminish the antihypertensive effect of Metoprolol. Mirabegron may increase the serum concentration of Metoprolol. Risk C: Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

NIFEdipine: May enhance the hypotensive effect of Beta-Blockers. NIFEdipine may enhance the negative inotropic effect of Beta-Blockers. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May diminish the antihypertensive effect of Beta-Blockers. Risk C: Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider therapy modification

Opioids (Anilidopiperidine): May enhance the bradycardic effect of Beta-Blockers. Opioids (Anilidopiperidine) may enhance the hypotensive effect of Beta-Blockers. Risk C: Monitor therapy

Panobinostat: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Perhexiline: CYP2D6 Substrates (High risk with Inhibitors) may increase the serum concentration of Perhexiline. Perhexiline may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Propafenone: May increase the serum concentration of Beta-Blockers. Propafenone possesses some independent beta blocking activity. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

QuiNINE: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Regorafenib: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy

Reserpine: May enhance the hypotensive effect of Beta-Blockers. Risk C: Monitor therapy

Rifamycin Derivatives: May decrease the serum concentration of Beta-Blockers. Exceptions: Rifabutin. Risk C: Monitor therapy

Rivastigmine: May enhance the bradycardic effect of Beta-Blockers. Risk X: Avoid combination

Ruxolitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Management: Ruxolitinib Canadian product labeling recommends avoiding use with bradycardia-causing agents to the extent possible. Risk C: Monitor therapy

Selective Serotonin Reuptake Inhibitors: May increase the serum concentration of Beta-Blockers. Exceptions: Citalopram; Escitalopram; FluvoxaMINE. Risk C: Monitor therapy

Sulfonylureas: Beta-Blockers may enhance the hypoglycemic effect of Sulfonylureas. Cardioselective beta-blockers (eg, acebutolol, atenolol, metoprolol, and penbutolol) may be safer than nonselective beta-blockers. All beta-blockers appear to mask tachycardia as an initial symptom of hypoglycemia. Ophthalmic beta-blockers are probably associated with lower risk than systemic agents. Risk C: Monitor therapy

Terlipressin: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Theophylline Derivatives: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Theophylline Derivatives. Management: Monitor for reduced theophylline efficacy during concomitant use with any beta-blocker. Beta-1 selective agents are less likely to antagonize theophylline than nonselective agents, but selectivity may be lost at higher doses. Risk C: Monitor therapy

Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Yohimbine: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Food Interactions

Food increases absorption. Metoprolol serum levels may be increased if taken with food. Management: Take immediate release tartrate tablets with food; succinate can be taken with or without food.

Monitoring Parameters

Acute cardiac treatment: Monitor ECG, heart rate, and blood pressure with IV administration; heart rate, rhythm, and blood pressure with oral administration.

IV use in a nonemergency situation: Necessary monitoring for surgical patients who are unable to take oral beta-blockers (because of prolonged ileus) has not been defined. Some institutions require monitoring of baseline and postinfusion heart rate and blood pressure when a patient’s response to beta-blockade has not been characterized (ie, the patient’s initial dose or following a change in dose). Consult individual institutional policies and procedures.

Hypertension: The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (ACC/AHA [Whelton 2017]):

Confirmed hypertension and known CVD or 10-year ASCVD risk ≥10%: Target blood pressure <130/80 mm Hg is recommended.

Confirmed hypertension without markers of increased ASCVD risk: Target blood pressure <130/80 mm Hg may be reasonable.

Advanced Practitioners Physical Assessment/Monitoring

Monitor blood pressure and cardiac status. Assess for fluid balance, heart failure symptoms, and postural hypotension. Taper dosage slowly when discontinuing. Report abdominal pain, unusual bleeding or bruising, or changes in color of urine or stool. Advise patients with diabetes to monitor glucose levels closely; beta-blockers may alter glucose tolerance.

Nursing Physical Assessment/Monitoring

Monitor blood pressure and cardiac status. Monitor for fluid balance, heart failure symptoms, and postural hypotension. Taper dosage slowly when discontinuing. Report abdominal pain; unusual bleeding or bruising; or changes in color of urine or stool. Advise patients with diabetes to monitor glucose levels closely; beta-blockers may alter glucose tolerance.

Dosage Forms Considerations

The extended release metoprolol succinate products’ strengths are expressed as metoprolol tartrate equivalents.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule ER 24 Hour Sprinkle, Oral:

Kapspargo Sprinkle: 25 mg, 50 mg, 100 mg, 200 mg [contains corn starch]

Solution, Intravenous, as tartrate:

Generic: 5 mg/5 mL (5 mL)

Solution, Intravenous, as tartrate [preservative free]:

Lopressor: 5 mg/5 mL (5 mL [DSC])

Generic: 5 mg/5 mL (5 mL)

Solution Cartridge, Intravenous, as tartrate:

Generic: 5 mg/5 mL (5 mL)

Tablet, Oral, as tartrate:

Lopressor: 50 mg [scored]

Lopressor: 100 mg [scored; contains fd&c blue #2 aluminum lake]

Generic: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg

Tablet Extended Release 24 Hour, Oral, as succinate:

Toprol XL: 25 mg

Toprol XL: 25 mg [scored]

Toprol XL: 50 mg

Toprol XL: 50 mg [DSC] [scored]

Toprol XL: 100 mg

Toprol XL: 100 mg [scored]

Toprol XL: 200 mg

Toprol XL: 200 mg [DSC] [scored]

Generic: 25 mg, 50 mg, 100 mg, 200 mg

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intravenous, as tartrate:

Betaloc: 5 mg/5 mL (5ml[DSC])

Lopresor: 5 mg/5 mL (5ml)

Generic: 5 mg/5 mL (5ml)

Tablet, Oral, as tartrate:

Lopresor: 50 mg, 100 mg

Generic: 25 mg, 50 mg, 100 mg

Tablet Extended Release 24 Hour, Oral:

Lopresor SR: 100 mg, 200 mg

Generic: 100 mg, 200 mg

Anatomic Therapeutic Chemical (ATC) Classification
  • C07AB02
Generic Available (US)

May be product dependent

Pricing: US

Capsule ER 24 Hour Sprinkle (Kapspargo Sprinkle Oral)

25 mg (per each): $1.74

50 mg (per each): $1.74

100 mg (per each): $2.30

200 mg (per each): $3.54

Solution (Metoprolol Tartrate Intravenous)

5 mg/5 mL (per mL): $0.24 – $0.65

Solution Cartridge (Metoprolol Tartrate Intravenous)

5 mg/5 mL (per mL): $1.39

Tablet, 24-hour (Metoprolol Succinate ER Oral)

25 mg (per each): $1.05 – $1.28

50 mg (per each): $1.05 – $1.28

100 mg (per each): $1.53 – $2.04

200 mg (per each): $2.52 – $3.06

Tablet, 24-hour (Toprol XL Oral)

25 mg (per each): $1.43

50 mg (per each): $1.58

100 mg (per each): $2.16

200 mg (per each): $3.77

Tablets (Lopressor Oral)

50 mg (per each): $2.76

100 mg (per each): $4.13

Tablets (Metoprolol Tartrate Oral)

25 mg (per each): $0.03 – $0.28

37.5 mg (per each): $1.46

50 mg (per each): $0.03 – $0.64

75 mg (per each): $2.44

100 mg (per each): $0.04 – $0.91

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer’s AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Selective inhibitor of beta1-adrenergic receptors; competitively blocks beta1-receptors, with little or no effect on beta2-receptors at oral doses <100 mg (in adults); does not exhibit any membrane stabilizing or intrinsic sympathomimetic activity

Pharmacodynamics/Kinetics

Note: The pharmacokinetics of metoprolol succinate extended-release capsule or tablet in hypertensive children and adolescents 6 to 17 years of age were found to be similar to adults.

Onset of action: Oral: Immediate release tablets: Within 1 hour; Peak effect: Oral: 1 to 2 hours (Regardh 1980); IV: 20 minutes (when infused over 10 minutes)

Duration: Oral: Immediate release: Variable (dose-related; 50% reduction in maximum heart rate after single doses of 20, 50, and 100 mg occurred at 3.3, 5, and 6.4 hours, respectively); Extended release: ~24 hours

Absorption: Rapid and complete

Distribution: Vd: 3.2 to 5.6 L/kg; crosses the blood brain barrier; CSF concentrations are 78% of plasma concentrations

Protein binding: ~10% to 12% to albumin

Metabolism: Extensively hepatic via CYP2D6; significant first-pass effect (~50%)

Bioavailability: Oral: Immediate release: ~40% to 50% (Johnsson 1975); Extended release: 77% relative to immediate release

Half-life elimination: Neonates: 5 to 10 hours (Morselli 1989); Adults: 3 to 4 hours (7 to 9 hours in poor CYP2D6 metabolizers or hepatic impairment)

Excretion: Urine (95%, <5% to 10% as unchanged drug; increased to 30% to 40% in poor CYP2D6 metabolizers)

Pharmacodynamics/Kinetics: Additional Considerations

Hepatic function impairment: Elimination half-life may be considerably prolonged, depending on severity.

Race: Poor CYP2D6 metabolizers (~8% Caucasians; ~2% other populations) have several-fold higher metoprolol plasma concentrations.

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

Metoprolol is a cardioselective beta-blocker. Local anesthetic with vasoconstrictor can be safely used in patients medicated with metoprolol. Nonselective beta-blockers (ie, propranolol, nadolol) enhance the pressor response to epinephrine, resulting in hypertension and bradycardia; this has not been reported for metoprolol. Many nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can reduce the hypotensive effect of beta-blockers after 3 or more weeks of therapy with the NSAID. Short-term NSAID use (ie, 3 days) requires no special precautions in patients taking beta-blockers.

Effects on Bleeding

No information available to require special precautions

Index Terms

Metoprolol Succinate; Metoprolol Tartrate

FDA Approval Date
August 07, 1978
References

Acikel S, Bozbas H, Gultekin B, et al. Comparison of the efficacy of metoprolol and carvedilol for preventing atrial fibrillation after coronary bypass surgery. Int J Cardiol. 2008;126(1):108-113.[PubMed 17499863]

Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published online October 30, 2017]. Circulation. doi: 10.1161/CIR.0000000000000549.[PubMed 29084731]

American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. Committee Opinion No. 623: emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521-525.[PubMed 25611642]

American College of Obstetricians and Gynecologists (ACOG), Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-1131.[PubMed 24150027]

Amsterdam EA, Wenger NK, Brindis RG, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association for Clinical Chemistry. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014;64(24):2713-2714]. J Am Coll Cardiol. 2014;64(24):e139-e228. doi: 10.1016/j.jacc.2014.09.017.[PubMed 25260718]

Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016 Jul;100(1):42-52.[PubMed 27060684]

Aroesty JM, Simons M, Breall JA. Overview of the non-acute management of unstable angina and non-ST elevation myocardial infarction. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 7, 2018.

Aronow WS, Fleg JL, Pepine CJ, et al; ACCF Task Force. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents [published corrections appear in Circulation. 2011;123(21):e616; Circulation. 2011;124(5):e175; Circulation. 2016;133(24):e715]. Circulation. 2011;123(21):2434-2506.[PubMed 21518977]

Bajwa ZH, Smith JH. Preventive treatment of migraine in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 7, 2018.

Chatzidou S, Kontogiannis C, Tsilimigras DI, et al. Propranolol versus metoprolol for treatment of electrical storm in patients with implantable cardioverter-defibrillator. J Am Coll Cardiol.2018;71(17):1897-1906. doi: 10.1016/j.jacc.2018.02.056.[PubMed 29699616]

Chaudhary I. Microvascular angina: angina pectoris with normal coronary arteries. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 22, 2018.

Chen ZM, Pan HC, Chen YP, et al; COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1622-1632.[PubMed 16271643]

Colucci WS. Use of beta blockers in heart failure with reduced ejection fraction. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 16, 2018.

Diener HC, Hartung E, Chrubasik J, et al; Study Group. A comparative study of oral acetylsalicyclic acid and metoprolol for the prophylactic treatment of migraine. A randomized, controlled, double-blind, parallel group phase III study. Cephalalgia. 2001;21(2):120-128.[PubMed 11422094]

Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999;353(9169):2001-2007.[PubMed 10376614]

Field JM, Hazinski MF, Sayre MR, et al, “Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” Circulation, 2010, 122 (18 Suppl 3):640-56.[PubMed 20956217]

Fihn SD, Gardin JM, Abrams J, et al; American College of Cardiology Foundation/American Heart Association Task Force. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons [published correction appears in Circulation. 2014;129(16):e463]. Circulation. 2012;126(25):e354-e471. doi: 10.1161/CIR.0b013e318277d6a0.[PubMed 23166211]

Foster CA and Aston SJ, “Propranolol-Epinephrine Interaction: A Potential Disaster,” Plast Reconstr Surg, 1983, 72(1):74-8.[PubMed 6867180]

Gersh BJ, Maron BJ, Bonow RO, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Failure Society of America; Heart Rhythm Society; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(24):e783-e831. doi: 10.1161/CIR.0b013e318223e2bd.[PubMed 22068434]

Grundmann M, Kacirova I, Duricova, J et al. “Metoprolol and alfa-hydroxymetoprolol concentrations during lactation-a case report.” 12th International Congress of Therapeutic Drug Monitoring and Clinical Toxicology Stuttgart, Germany · October 2 – 6, 2011. Ther Drug Monit. 2011;33(4):504.

Haghjoo M, Saravi M, Hashemi MJ, et al. Optimal beta-blocker for prevention of atrial fibrillation after on-pump coronary artery bypass graft surgery: carvedilol versus metoprolol. Heart Rhythm. 2007;4(9):1170-1174.[PubMed 17765616]

Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published corrections appear in Circulation. 2012;126(7):e105; Circulation. 2011;124(25):e956]. Circulation. 2011;124(23):2610-2642.[PubMed 22064600]

Hiratzka LF, Bakris GL, Beckman JA, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation [published correction appears in Circulation. 2010;122(4):e410]. 2010;121(13):e266-e369. doi: 10.1161/CIR.0b013e3181d4739e.[PubMed 20233780]

Hirsch AT, Haskal ZJ, Hertzer NR, et al, “ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): Executive Summary. A Collaborative Report of the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease),” Circulation , 2006, 113(11):1474-1547.[PubMed 16549646]

Ho TK, Moretti ME, Schaeffer JK et al. Maternal beta-blocker usage and breast feeding in the neonate. The American Pediatric Society and The Society for Pediatric Research 1999 annual meeting. San Francisco, California, USA. May 1-4, 1999. Abstracts. Pediatr Res. 1999;45(4 Pt 2):67A.[PubMed 10372206]

Huckleberry Y, Thomas MC, Erstad BL. Dosage conversions as a potential cause of adverse drug events. Am J Health Syst Pharm. 2003;60(2):189-191.[PubMed 12561664]

Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126.[PubMed 10891521]

James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.[PubMed 24352797]

January CT, Wann LS, Alpert JS, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2014;64(21):2305-2307]. J Am Coll Cardiol. 2014;64(21):e1-e76. doi: 10.1016/j.jacc.2014.03.022.[PubMed 24685669]

Johnsson G, Regårdh CG, Sölvell L. Combined pharmacokinetic and pharmacodynamic studies in man of the adrenergic beta1-receptor antagonist metoprolol. Acta Pharmacol Toxicol (Copenh). 1975;36(suppl 5):31-44.[PubMed 1094802]

Kannam JP, Aroesty JM, Gersh BJ. Beta blockers in the management of stable ischemic heart disease. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 7, 2018.

Kapspargo (metoprolol) [prescribing information]. Cranbury, NJ: Sun Pharmaceuticals; May 2018.

Kettering K, Mewis C, Dörnberger V, Vonthein R, Bosch RF, Kühlkamp V. Efficacy of metoprolol and sotalol in the prevention of recurrences of sustained ventricular tachyarrhythmias in patients with an implantable cardioverter defibrillator. Pacing Clin Electrophysiol. 2002;25(11):1571-1576.[PubMed 12494613]

Kuck KH, Cappato R, Siebels J, Rüppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH). Circulation. 2000;102(7):748-754.[PubMed 10942742]

Lee R. Atrial fibrillation and flutter after cardiac surgery. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 7, 2018.

Liedholm H, Melander A, Bitzén PO, et al, “Accumulation of Atenolol and Metoprolol in Human Breast Milk,” Eur J Clin Pharmacol, 1981, 20(3):229-31.[PubMed 7286041]

Lindeberg S, Lundborg P, Regårdh CG, et al, “Disposition of the Adrenergic Blocker Metoprolol and its Metabolite OH-Metoprolol in Maternal Plasma, Amniotic Fluid and Capillary Blood of the Neonate,” Eur J Clin Pharmacol, 1987, 33(4):363-8.[PubMed 3443141]

Lopressor (metoprolol tartrate, USP) tablets [prescribing information]. Parsippany, NJ: Validus Pharmaceuticals LLC; September 2017.

Lopressor (metoprolol) [product monograph]. Dorval, Quebec, Canada: Novartis Pharmaceuticals Canada Inc; May 2016.

Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P, Canadian Hypertensive Disorders of Pregnancy Working Group. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014;36(5):416-441.[PubMed 24927294]

Mayer S, Hillis LD. Prinzmetal’s variant angina. Clin Cardiol. 1998;21(4):243-246.[PubMed 9562933]

Melander A, Danielson K, Scherstén B, Wåhlin E. Enhancement of the bioavailability of propranolol and metoprolol by food. Clin Pharmacol Ther. 1977;22(1):108-112.[PubMed 872491]

MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999;353(9169):2001-2007.[PubMed 10376614]

Metoprolol tartrate injection ampuls [prescribing information]. Lake Forest, IL: Hospira; September 2015.

Metoprolol tartrate injection vials [prescribing information]. Lake Forest, IL: Hospira; October 2015.

Metoprolol tartrate tablets [prescribing information]. Morgantown, WV: Mylan Pharmaceuticals; March 2015.

Morselli PL, Boutroy MJ, Bianchetti G, et al, “Pharmacokinetics of Antihypertensive Drugs in the Neonatal Period,” Dev Pharmacol Ther, 1989, 13(2-4):190-8.[PubMed 2693002]

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(suppl 2):555-576.[PubMed 15286277]

National Institutes of Health, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Clinical Practice Guidelines, 2011. Available at http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf.

Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care [published corrections appear in Circulation. 2011;123(6):e236; Circulation. 2013;128(25):e480]. Circulation. 2010;122(18)(suppl 3):S729-S767. doi: 10.1161/CIRCULATIONAHA.110.970988.[PubMed 20956224]

Nishimura RA, Otto CM, Bonow RO, et al, 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):2440-92. doi: 10.1161/CIR.0000000000000029.[PubMed 24589852]

O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2013;128(25):e481]. Circulation. 2013;127(4):e362-e425.[PubMed 23247304]

Olsson G, Wikstrand J, Warnold I, et al. Metoprolol-induced reduction in postinfarction mortality: pooled results from five double-blind randomized trials. Eur Heart J. 1992;13(1):28-32.[PubMed 1533587]

Ozaydin M, Icli A, Yucel H, et al. Metoprolol vs. carvedilol or carvedilol plus N-acetyl cysteine on post-operative atrial fibrillation: a randomized, double-blind, placebo-controlled study. Eur Heart J. 2013;34(8):597-604. doi: 10.1093/eurheartj/ehs423.[PubMed 23232844]

Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2016;68(25):2922-2923]. J Am Coll Cardiol. 2016;67(13):e27-e115.[PubMed 26409259]

Pringsheim T, Davenport W, Mackie G, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 Suppl 2):S1-59.[PubMed 22683887]

Regardh CG, Borg KO, Johansson R, Johnsson G, Palmer L. Pharmacokinetic studies on the selective beta1-receptor antagonist metoprolol in man. J Pharmacokinet Biopharm. 1974;2(4):347-364.[PubMed 4155762]

Regardh CG and Johnsson G, “Clinical Pharmacokinetics of Metoprolol,” Clin Pharmacokinet, 1980, 5(6):557-69.[PubMed 7002420]

Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147-3197.[PubMed 21873418]

Rosendorff C, Lackland DT, Allison M, et al; American Heart Association, American College of Cardiology, and American Society of Hypertension. Treatment of hypertension in patients with coronary artery disease: A scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Soc Hypertens. 2015;9(6):453-498. doi: 10.1016/j.jash.2015.03.002.[PubMed 25840695]

Rosenson RS, Reeder GS, Kennedy HL. Acute myocardial infarction: role of beta blocker therapy. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 7, 2018.

Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis [published correction appears in Thyroid. 2017;27(11):1462]. Thyroid. 2016;26(10):1343-1421. doi: 10.1089/thy.2016.0229.[PubMed 27521067]

Ryu RJ, Eyal S, Easterling TR, et al. Pharmacokinetics of metoprolol during pregnancy and lactation. J Clin Pharmacol. 2016;56(5):581-589.[PubMed 26461463]

Sandström B, Lindeberg S, Lundborg P, Regardh CG. Disposition of the adrenergic blocker metoprolol in the late pregnant women, the amniotic fluid, the cord blood and the neonate. Clin Exp Hypertens B. 1983;2(1):75-82.[PubMed 6135523]

Schellenberg R, Lichtenthal A, Wöhling H, Graf C, Brixius K. Nebivolol and metoprolol for treating migraine: an advance on beta-blocker treatment? Headache. 2008;48(1):118-125. doi: 10.1111/j.1526-4610.2007.00785.x.[PubMed 18184294]

Seidl K, Hauer B, Schwick NG, Zahn R, Senges J. Comparison of metoprolol and sotalol in preventing ventricular tachyarrhythmias after the implantation of a cardioverter/defibrillator. Am J Cardiol. 1998;82(6):744-748.[PubMed 9761084]

Silberstein SD, Holland S, Freitag F, et al; Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society [published correction appears in Neurology. 2013;80(9):871]. Neurology. 2012;78(17):1337-1345.[PubMed 22529202]

Simons M, Breall JA. Overview of the non-acute management of unstable angina and non-ST elevation myocardial infarction. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 16, 2018.

Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12(8):767-778.[PubMed 20675664]

Smith SC Jr, Benjamin EJ, Bonow RO, et al, “AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: A Guideline From the American Heart Association and American College of Cardiology Foundation,” Circulation, 2011, 124(22):2458-73.[PubMed 22052934]

Tangeman HJ, Patterson JH. Extended-release metoprolol succinate in chronic heart failure. Ann Pharmacother. 2003;37(5):701-710.[PubMed 12708950]

Toprol XL (metoprolol) [prescribing information]. Princeton, NJ: Aralez Pharmaceuticals; December 2016.

van den Berg G, van Steveninck F, Gubbens-Stibbe JM, Schoemaker HC, de Boer AG, Cohen AF. Influence of food on the bioavailability of metoprolol from an OROS system; a study in healthy volunteers. Eur J Clin Pharmacol. 1990;39(3):315-316.[PubMed 2257873]

Weber MA, Schiffrin EL, White WB, et al, Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich). 2014;16(1):14-26.[PubMed 24341872]

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published online ahead of print on November 13, 2017]. Hypertension. doi: 10.1161/HYP.0000000000000065.[PubMed 29133356]

Wikstrand J, Andersson B, Kendall MJ, Stanbrook H, Klibaner M. Pharmacokinetic considerations of formulation: extended-release metoprolol succinate in the treatment of heart failure. J Cardiovasc Pharmacol. 2003;41(2):151-157.[PubMed 12548073]

Wynn RL, “Dental Nonsteroidal Anti-inflammatory Drugs and Prostaglandin-Based Drug Interactions, Part Two,” Gen Dent, 1992, 40(2):104, 106, 108.[PubMed 1354194]

Wynn RL, “Epinephrine Interactions With Beta-Blockers,” Gen Dent, 1994, 42(1):16, 18.[PubMed 7911769]

Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America [published online May 20, 2016]. Circulation. doi: 10.1161/CIR.0000000000000435.[PubMed 27208050]

Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776-803. doi: 10.1016/j.jacc.2017.04.025.[PubMed 28461007]

Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128(16):e240-e327.[PubMed 23741058]

Zimetbaum PJ, Wylie JV. Nonsustained ventricular tachycardia: Clinical manifestations, evaluation, and management. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 16, 2018.

Brand Names: International

Angilat (BD); Angimet (PH); Beloc (AR, AT, CO, DE); Beloc Duriles (AT); Beloc Zok (CH); Beloken (ES, IE); Beloken Retard (ES); Belozok (AR, CO, PE, UY); Betacard (BD); Betaloc (AU, BD, CN, CO, EG, GB, HK, HU, IE, IN, KR, LK, LT, LV, MY, PH, PL, RO, RU, SI, SK, VN); Betaloc CR (NZ); Betaloc Zoc (BF, BJ, CI, GH, GM, GN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM, ZW); Betaloc ZOK (BG, ET, LV, NO, VN); Betaloc Zok (CO, CY, CZ, DE, EC, EE, HK, HR, HU, JO, KW, LK, LT, PK, PL, RO, SK, TR, TW); Betaloc Zox (CN); Betaloc-ZOK (CL); Betalok (UA); Betawin (MY); Betazok (PH); Bloxan (HR, RO); Bloxazoc (BG, CZ, EE, HU, IS, PL, RO, SK); Cardeloc (TH); Cardiosel (PH); Cardiosel-OD (PH); Cardiostat (PH); Cardiotab (PH); Cardoxone (TR); Corvital (UA); Corvitol (LV); Denex (MY, SG, TH, TR); Egilok (UA, VN); Egilok Succ (CZ); Emzok (LV); Huma-Metoprol (HU); Hypetor (PH); Jutabloc (DE); Lofarbil (GR); Lopresor (AE, AR, AT, AU, BF, BH, BJ, BM, BS, BZ, CI, CL, CY, CZ, ES, ET, GH, GM, GN, GR, GY, IE, IQ, IR, IT, JM, JO, KE, KW, LB, LR, LU, LY, MA, ML, MR, MU, MW, MX, NE, NG, NZ, OM, PT, PY, QA, SA, SC, SD, SL, SN, SR, SY, TN, TT, TZ, UG, UY, VE, YE, ZA, ZM, ZW); Lopresor Divitab (IL); Lopresor OROS (LU); Lopresor Retard (AE, AT, CH, GR, IT, PT); Lopressor (BB, BR, FR); Loprolol (ID); Low Press (EG); Metazero (LT, LV); Meto-Hennig (DE); Metocell (NL); Metocor (IE); Metohexal (DE, HU, LU); MetoHEXAL (VN); Metohexal Retard (AT); Metolol-CP (HK); Metoprim (PH); Metoprogamma (DE); Metoprolol Stada (HU); Metoprolol-B (HU); Metoprolol-rpm (LU); Metostad (BG, PH); Metracin (HK); Metrol (AU); Mezelol (MX); Minax (AU, HK, TW); Myloc CR (NZ); Neobloc (IL); Neox (PH); Nipresol (MX); Prolol (BD); Prolomet XL (LK); Promiced (MX); Revelol XL (LK); Revelol-XL-50 (ZW); Ritmetol (HU); Sefloc (TH); Selo-zok (DK, NO); Selokeen ZOC (NL); Seloken (DK, FI, FR, IS, IT, JP, LU, NO, SE); Seloken Retard (AT, IT); Seloken Zoc (FI, SE); Seloken Zok (IS, VE); Seloken-Zok (MX); Selopral (FI); Selozok (BE, BR, DK, LU); Selozok LP (FR); Slow-Lopresor (LU, NZ); Succiprol (BG); Tadilor (CR, DO, GT, HN, NI, PA, SV); Topress (BD); Toprol XL (AU); Vasocardin (BG); Voxuten (LV)

Metoprolol (Patient Education – Adult Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(me toe PROE lole)

Brand Names: US

Kapspargo Sprinkle; Lopressor; Toprol XL

Brand Names: Canada

Betaloc; Lopresor; Lopresor SR

Warning
  • Do not stop taking this drug all of a sudden. If you do, chest pain that is worse and in some cases heart attack may occur. The risk may be greater if you have certain types of heart disease. To avoid side effects, you will want to slowly stop this drug as ordered by your doctor. Call your doctor right away if you have new or worse chest pain or if other heart problems occur.
What is this drug used for?
  • It is used to treat high blood pressure.
  • It is used to treat chest pain or pressure.
  • It is used to treat heart failure (weak heart).
  • It is used after a heart attack to help prevent future heart attacks and lengthen life.
  • It may be given to you for other reasons. Talk with the doctor.
What do I need to tell my doctor BEFORE I take this drug?
  • If you have an allergy to metoprolol or any other part of this drug.
  • If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If you have any of these health problems: Certain types of abnormal heartbeats called heart block or sick-sinus syndrome, heart failure (weak heart), low blood pressure, poor blood flow to the arms or legs, shock caused by heart problems, or a slow heartbeat.
  • If you have any of these health problems: Asthma or other breathing problems like COPD (chronic obstructive pulmonary disease).
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.
What are some things I need to know or do while I take this drug?
  • All products:
  • Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists.
  • Avoid driving and doing other tasks or actions that call for you to be alert until you see how this drug affects you.
  • To lower the chance of feeling dizzy or passing out, rise slowly if you have been sitting or lying down. Be careful going up and down stairs.
  • Check blood pressure and heart rate as the doctor has told you. Talk with the doctor.
  • Have blood work checked as you have been told by the doctor. Talk with the doctor.
  • This drug may affect certain lab tests. Tell all of your health care providers and lab workers that you take this drug.
  • This drug may hide the signs of low blood sugar. Talk with the doctor.
  • If you have high blood sugar (diabetes), you will need to watch your blood sugar closely.
  • If you are taking this drug and have high blood pressure, talk with your doctor before using OTC products that may raise blood pressure. These include cough or cold drugs, diet pills, stimulants, ibuprofen or like products, and some natural products or aids.
  • This drug may make it harder to tell if you have signs of an overactive thyroid like fast heartbeat. If you have an overactive thyroid and stop taking this drug all of a sudden, it may get worse and could be life-threatening. Talk with your doctor.
  • If you have had a very bad allergic reaction, talk with your doctor. You may have a chance of an even worse reaction if you come into contact with what caused your allergy. If you use epinephrine to treat very bad allergic reactions, talk with your doctor. Epinephrine may not work as well while you are taking this drug.
  • Tell your doctor if you are pregnant or plan on getting pregnant. You will need to talk about the benefits and risks of using this drug while you are pregnant.
  • Tell your doctor if you are breast-feeding. You will need to talk about any risks to your baby.
  • Extended-release capsules:
  • Avoid drinking alcohol while taking this drug.
  • All other products:
  • Talk with your doctor before you drink alcohol.
What are some side effects that I need to call my doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Low mood (depression).
  • Very bad dizziness or passing out.
  • Chest pain that is new or worse.
  • A new or worse heartbeat that does not feel normal.
  • Slow heartbeat.
  • Shortness of breath, a big weight gain, or swelling in the arms or legs.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
  • Dizziness.
  • Feeling tired or weak.
  • Diarrhea.
  • Upset stomach or throwing up.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best taken?
  • Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.
  • All oral products:
  • Swallow whole. Do not chew or crush.
  • To gain the most benefit, do not miss doses.
  • Keep taking this drug as you have been told by your doctor or other health care provider, even if you feel well.
  • All tablet products:
  • Take with or right after a meal.
  • You may break the tablet in half. Do not chew or crush.
  • Extended-release capsules:
  • Take with or without food.
  • If you cannot swallow this drug whole, you may sprinkle the contents on applesauce, pudding, yogurt, or other soft food. If you do this, swallow the mixture within 60 minutes of mixing without chewing. Do not store for future use.
  • Those who have feeding tubes may use this drug. Use as you have been told. Flush the feeding tube after this drug is given.
  • Injection:
  • It is given as a shot into a vein.
What do I do if I miss a dose?
  • All oral products:
  • Skip the missed dose and go back to your normal time.
  • Do not take 2 doses at the same time or extra doses.
  • Injection:
  • Call your doctor to find out what to do.
How do I store and/or throw out this drug?
  • All oral products:
  • Store at room temperature.
  • Protect from heat.
  • Store in a dry place. Do not store in a bathroom.
  • Injection:
  • If you need to store this drug at home, talk with your doctor, nurse, or pharmacist about how to store it.
  • All products:
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
General drug facts
  • If your symptoms or health problems do not get better or if they become worse, call your doctor.
  • Do not share your drugs with others and do not take anyone else’s drugs.
  • Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor.
  • Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.
Metoprolol (Patient Education – Pediatric Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(me toe PROE lole)

Brand Names: US

Kapspargo Sprinkle; Lopressor; Toprol XL

Brand Names: Canada

Betaloc; Lopresor; Lopresor SR

Warning
  • Do not stop giving this drug to your child all of a sudden. If you do, chest pain that is worse and in some cases heart attack may occur. The chance may be higher if your child has certain types of heart disease. To avoid side effects, you will want to slowly stop this drug as ordered by the doctor. Call the doctor right away if your child has new or worse chest pain or if other heart problems happen.
What is this drug used for?
  • It is used to treat high blood pressure.
  • It may be given to your child for other reasons. Talk with the doctor.
What do I need to tell the doctor BEFORE my child takes this drug?
  • If your child has an allergy to this drug or any part of this drug.
  • If your child is allergic to any drugs like this one or any other drugs, foods, or other substances. Tell the doctor about the allergy and what signs your child had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If your child has any of these health problems: Certain types of abnormal heartbeats called heart block or sick-sinus syndrome, heart failure (weak heart), low blood pressure, poor blood flow to the arms or legs, shock caused by heart problems, or a slow heartbeat.
  • If your child has any of these health problems: Asthma or other breathing problems like COPD (chronic obstructive pulmonary disease).
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for your child to take this drug with all of his/her drugs and health problems. Do not start, stop, or change the dose of any drug your child takes without checking with the doctor.
What are some things I need to know or do while my child takes this drug?
  • Tell all of your child’s health care providers that your child is taking this drug. This includes your child’s doctors, nurses, pharmacists, and dentists.
  • Have your child’s blood pressure and heart rate checked often. Talk with your child’s doctor.
  • Have your child avoid tasks or actions that call for alertness until you see how this drug affects your child. These are things like riding a bike, playing sports, or using items such as scissors, lawnmowers, electric scooters, toy cars, or motorized vehicles.
  • To lower the chance of feeling dizzy or passing out, have your child rise slowly if your child has been sitting or lying down. Have your child be careful going up and down stairs.
  • Have blood work checked as you have been told by the doctor. Talk with the doctor.
  • This drug may affect certain lab tests. Tell all of your child’s health care providers and lab workers that your child takes this drug.
  • Alcohol may interact with this drug. Be sure your child does not drink alcohol.
  • This drug may hide the signs of low blood sugar. Talk with the doctor.
  • If your child has high blood sugar (diabetes), you will need to watch his/her blood sugar closely.
  • If your child is taking this drug and has high blood pressure, talk with the doctor before giving OTC products that may raise blood pressure. These include cough or cold drugs, diet pills, stimulants, ibuprofen or like products, and some natural products or aids.
  • This drug may make it harder to tell if your child has signs of an overactive thyroid like fast heartbeat. If your child has an overactive thyroid and stops taking this drug all of a sudden, it may get worse and could be life-threatening. Talk with the doctor.
  • If your child has had a very bad allergic reaction, talk with the doctor. Your child may have a chance of an even worse reaction if your child comes into contact with what caused the allergy. If your child uses epinephrine to treat very bad allergic reactions, talk with the doctor. Epinephrine may not work as well while your child is taking this drug.
  • If your child is breast-feeding a baby:
  • Talk with the doctor if your child is pregnant, becomes pregnant, or is breast-feeding a baby. You will need to talk about the benefits and risks to your child and the baby.
What are some side effects that I need to call my child’s doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your child’s doctor or get medical help right away if your child has any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Low mood (depression).
  • Very bad dizziness or passing out.
  • Chest pain that is new or worse.
  • A new or worse heartbeat that does not feel normal.
  • Slow heartbeat.
  • Shortness of breath, a big weight gain, or swelling in the arms or legs.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your child’s doctor or get medical help if any of these side effects or any other side effects bother your child or do not go away:
  • Dizziness.
  • Feeling tired or weak.
  • Diarrhea.
  • Upset stomach or throwing up.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your child’s doctor. Call your child’s doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best given?
  • Give this drug as ordered by your child’s doctor. Read all information given to you. Follow all instructions closely.
  • All oral products:
  • Have your child swallow whole. Do not let your child chew or crush.
  • To gain the most benefit, do not miss giving your child doses.
  • Keep giving this drug to your child as you have been told by your child’s doctor or other health care provider, even if your child feels well.
  • All tablet products:
  • Give with or right after a meal.
  • You may break the tablet in half. Do not let your child chew or crush.
  • Extended-release capsules:
  • Give this drug with or without food.
  • If your child cannot swallow this drug whole, you may sprinkle the contents on applesauce, pudding, yogurt, or other soft food. If you do this, have your child swallow the mixture within 60 minutes of mixing without chewing. Do not store for future use.
  • Those who have feeding tubes may use this drug. Use as you have been told. Flush the feeding tube after this drug is given.
  • Injection:
  • It is given as a shot into a vein.
What do I do if my child misses a dose?
  • All oral products:
  • Skip the missed dose and go back to your child’s normal time.
  • Do not give 2 doses at the same time or extra doses.
  • Injection:
  • Call your child’s doctor to find out what to do.
How do I store and/or throw out this drug?
  • All oral products:
  • Store at room temperature.
  • Protect from heat.
  • Store in a dry place. Do not store in a bathroom.
  • Injection:
  • If you need to store this drug at home, talk with your child’s doctor, nurse, or pharmacist about how to store it.
  • All products:
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
General drug facts
  • If your child’s symptoms or health problems do not get better or if they become worse, call your child’s doctor.
  • Do not share your child’s drug with others and do not give anyone else’s drug to your child.
  • Keep a list of all your child’s drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your child’s doctor.
  • Talk with your child’s doctor before giving your child any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your child’s doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.