Metoprolol contraindications
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Key Contraindications for Metoprolol Use
Metoprolol, a beta-blocker, is widely used for cardiovascular conditions but has several important contraindications that must be considered before prescribing.
Hypotension, Asthma, COPD, and Syncope
Patients with hypotension, asthma, chronic obstructive pulmonary disease (COPD), and a history of syncope are at increased risk of adverse effects from metoprolol. These conditions are commonly recognized as contraindications, as they can worsen with beta-blocker therapy. In a large cohort, 21% had hypotension, 48% had COPD, 15% had asthma, and 12% had syncope, and these conditions were associated with a lower likelihood of being prescribed metoprolol or other evidence-based beta-blockers after hospitalization for heart failure with reduced ejection fraction (HFrEF) . Additionally, metoprolol was shown to increase the risk of hospitalization for COPD exacerbations, indicating that it should be used with caution or avoided in patients with moderate to severe COPD who do not have a clear indication for beta-blocker therapy .
High Ejection Fraction in Atrial Fibrillation
For patients with atrial fibrillation and a high ejection fraction (normal heart function), metoprolol may increase the risk of heart failure, as indicated by elevated NT-pro BNP levels. Therefore, it is suggested that metoprolol should be contraindicated in these patients unless there is another compelling indication .
Central Nervous System (CNS) Effects in Elderly Patients
Elderly patients are particularly susceptible to CNS side effects from metoprolol, such as confusion, fatigue, nightmares, hallucinations, and sleep disturbances. These effects are more likely due to the drug’s lipophilic properties, which allow it to cross the blood-brain barrier. Close monitoring is recommended, and metoprolol should be avoided or discontinued if significant CNS symptoms develop 89.
CYP2D6 Poor Metabolizers and Risk of Bradycardia
Patients with poor CYP2D6 metabolism experience greater reductions in heart rate and blood pressure and are at a higher risk of bradycardia when taking metoprolol. This genetic variation may necessitate dose adjustments or alternative therapies to avoid adverse effects .
Other Considerations: Drug Interactions and Organ Dysfunction
Metoprolol’s pharmacokinetics can be significantly altered in patients with hepatic impairment, leading to decreased drug clearance and increased risk of toxicity. Renal impairment, on the other hand, may increase drug clearance. Drug-drug interactions are also common and can affect metoprolol levels, so careful review of concomitant medications is necessary .
Conclusion
Metoprolol is contraindicated or should be used with caution in patients with hypotension, asthma, COPD, syncope, high ejection fraction in atrial fibrillation, significant CNS side effects (especially in the elderly), poor CYP2D6 metabolism, and hepatic impairment. Careful patient selection and monitoring are essential to minimize risks and ensure safe use of metoprolol in clinical practice 1456789.
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