Metoprolol dosage guidelines
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Metoprolol Dosage Guidelines for Hypertension, Heart Failure, and Angina
Hypertension Dosage Recommendations
For hypertension, the usual starting dose of metoprolol succinate extended-release is 25 to 100 mg once daily. The dose can be increased at weekly or longer intervals until the desired blood pressure is achieved. Doses above 400 mg per day have not been studied and are not recommended . In elderly patients with moderate hypertension, both 100 mg and 200 mg daily were effective, but 100 mg was better tolerated and is preferred for older adults .
Heart Failure Dosage Guidelines
For heart failure, the recommended starting dose is 12.5 mg or 25 mg once daily. The dose should be doubled every two weeks to the highest tolerated dose, up to a maximum of 200 mg daily . In real-world settings, only about 26% of patients reach the target dose of 200 mg before device implantation, indicating that many patients may not tolerate or reach the maximum recommended dose .
Angina Pectoris Dosage
For angina, the usual initial dose is 100 mg once daily. The dose can be gradually increased at weekly intervals until the optimal clinical response is achieved or until side effects, such as bradycardia, become unacceptable. Doses above 400 mg per day have not been studied .
Immediate-Release vs. Extended-Release Formulations
Metoprolol succinate (extended-release) can be administered once daily, which helps with patient compliance 34. When switching from immediate-release to extended-release, the same total daily dose should be used . For immediate-release metoprolol, a single daily dose of 300 mg is effective for lowering blood pressure, but dividing the dose into three daily doses results in more stable drug levels and beta-blockade throughout the day. However, the difference in blood pressure control between single and divided doses is not significant .
Dosage Adjustments Based on Patient Characteristics
Age
Older adults tolerate lower doses better, with 100 mg daily being effective and preferred over higher doses for elderly hypertensive patients .
Gender
Women may require lower doses than men to achieve similar drug exposure. A 50 mg dose in adult women provides similar drug exposure to a 100 mg dose in adult men, suggesting that gender-based dose adjustments may be appropriate, even though current guidelines do not specify this 79.
Heart Rate and Titration
For heart failure and post-myocardial infarction, metoprolol is often titrated to achieve a target heart rate (e.g., 55–60 beats per minute), with maintenance doses typically ranging from 25 to 50 mg daily, adjusted based on patient response and tolerability 610.
Interindividual Variability and Monitoring
There is significant variability in metoprolol blood levels among patients taking the same dose, influenced by factors such as body weight and genetic differences in drug metabolism (e.g., cytochrome 2D6 status). Monitoring drug levels may help identify patients at risk of underdosing or toxicity, especially in those with heart failure .
Conclusion
Metoprolol dosing should be individualized based on the condition being treated, patient age, gender, and response to therapy. For hypertension and angina, starting doses typically range from 25 to 100 mg once daily, with gradual increases as needed. In heart failure, start with 12.5–25 mg and titrate up to 200 mg as tolerated. Lower doses are often sufficient and better tolerated in elderly patients and women. Regular monitoring and dose adjustments are important due to variability in drug response among individuals.
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