Metoprolol hypoglycemia

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Metoprolol and Hypoglycemia: A Comprehensive Review

Introduction to Metoprolol and Hypoglycemia

Metoprolol, a beta-1 selective adrenergic blocker, is commonly used to manage cardiovascular conditions such as hypertension and angina. However, its effects on glucose metabolism, particularly in the context of hypoglycemia, are of significant clinical interest, especially for patients with diabetes mellitus.

Metoprolol's Impact on Hypoglycemia in Diabetic Patients

Impaired Glucose Recovery

Research indicates that metoprolol can impair glucose recovery from insulin-induced hypoglycemia in patients with insulin-dependent diabetes mellitus (IDDM). This impairment is similar to that observed with nonselective beta-blockers like propranolol, suggesting that metoprolol is not necessarily safer in this context 16. The delayed recovery is attributed to the inhibition of counterregulatory mechanisms, particularly the epinephrine-mediated beta-adrenergic pathways, which are crucial for glucose mobilization during hypoglycemia .

Hormonal Responses and Symptom Awareness

Metoprolol has been shown to alter the thresholds for the release of counterregulatory hormones. For instance, it triggers epinephrine release at higher plasma glucose levels compared to placebo, although it does not affect the thresholds for other hormones like glucagon and cortisol . Despite these hormonal changes, metoprolol does not significantly alter the awareness of hypoglycemic symptoms, which is crucial for patient safety 34.

Comparative Effects with Other Beta-Blockers

Hemodynamic Responses

Studies comparing metoprolol with other beta-blockers such as oxprenolol and propranolol reveal differences in their hemodynamic effects during hypoglycemia. Metoprolol tends to lower systolic blood pressure without causing bradycardia, whereas oxprenolol increases diastolic pressure and propranolol induces bradycardia and a pressor response 125. These variations highlight the need for careful selection of beta-blockers based on individual patient profiles and comorbidities.

Metabolic Effects

Both metoprolol and propranolol impair glucose recovery, but metoprolol may have a less pronounced effect on glucose metabolism during pharmacologic hyperglucagonemia in hemodialysis patients, suggesting a potentially safer profile in this specific population . Additionally, metoprolol, along with other beta-blockers, enhances sweating during hypoglycemia, which can be a useful clinical sign for detecting hypoglycemia .

Clinical Implications and Recommendations

Preoperative Considerations

There are reports of severe hypoglycemia associated with preoperative administration of metoprolol, indicating the need for careful monitoring and possibly adjusting the dosing regimen in the perioperative period . This is particularly important for patients with underlying metabolic abnormalities.

Preventing QT Interval Prolongation

Interestingly, metoprolol has been found to prevent hypoglycemia-induced QT interval prolongation, a condition that can lead to fatal ventricular arrhythmias. This protective effect is shared with other agents like diltiazem and pilocarpine, suggesting a potential role for metoprolol in managing hypoglycemia-induced cardiac risks .

Conclusion

Metoprolol, while effective for cardiovascular management, poses significant challenges in the context of hypoglycemia, particularly for diabetic patients. Its impact on glucose recovery, hormonal responses, and hemodynamic parameters necessitates careful consideration and monitoring. Comparative studies with other beta-blockers provide valuable insights, but individualized patient care remains paramount to mitigate the risks associated with hypoglycemia.

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Most relevant research papers on this topic

Beta blockade and diabetes mellitus: effect of oxprenolol and metoprolol on the metabolic, cardiovascular, and hormonal response to insulin-induced hypoglycemia in insulin-dependent diabetics.

Both oxprenolol and metoprolol do not accelerate insulin-induced hypoglycemia in insulin-dependent diabetics, but oxprenolol may have a greater impact on hemodynamic response to hypoglycemia.

RCT

1980·

29citations

·G. Viberti et al.

Beta blockade and diabetes mellitus: effect of oxprenolol and metoprolol on the metabolic, cardiovascular, and hormonal response to insulin-induced hypoglycemia in normal subjects.

Both oxprenolol and metoprolol delay hypoglycemia recovery, but oxprenolol raises diastolic blood pressure during hypoglycemia.

1980·

30citations

·G. Viberti et al.

Beta-adrenoceptor blockade and hypoglycaemia. A randomised, double-blind, placebo controlled comparison of metoprolol CR, atenolol and propranolol LA in normal subjects.

Beta-adrenoceptor antagonists modify physiological and hormonal responses to moderate hypoglycemia in healthy volunteers, but do not adversely affect awareness of the condition.

RCT

1990·

46citations

·David Kerr et al.

The effect of selective β1-blockade on glucose thresholds for release of counterregulatory hormones and symptoms in insulin-dependent diabetes mellitus

Beta 1-blockade alters counterregulatory hormone responses but does not change hypoglycemic symptoms thresholds in insulin-dependent diabetes mellitus patients.

RCT

1992·

2citations

·H. Vea et al.

Plasma catecholamines and cardiovascular responses to hypoglycemia in hyperthyroidism before and during treatment with metoprolol or propranolol.

Metoprolol and propranolol treatment in hyperthyroid patients increases plasma epinephrine during hypoglycemia, while propranolol completely blocks hypoglycemia-induced tachycardia and lowers basal heart rate.

Non-RCT

1980·

12citations

·O. Nilsson et al.

Oral Propranolol and Metoprolol Both Impair Glucose Recovery from Insulin-induced Hypoglycemia in Insulin-dependent Diabetes Mellitus

Both oral propranolol and metoprolol impair glucose recovery from insulin-induced hypoglycemia in patients with insulin-dependent diabetes mellitus, making them both potentially unsafe.

1984·

63citations

·D. Popp et al.

Hypoglycemia associated with preoperative metoprolol administration.

Metoprolol administration before surgery may cause severe hypoglycemia in patients with underlying energy requirements or metabolism issues.

Case Report

2004·

9citations

·Daniel R. Brown et al.

Comparison of propranolol, metoprolol, and acebutolol on insulin-induced hypoglycaemia.

Propranolol and metoprolol both potentiate insulin-induced hypoglycemia and delay return to normal blood glucose levels, while acebutolol also potentiates but does not delay return to normal blood glucose levels.

Non-RCT

1976·

68citations

·R. Newman

The Prophylactic Effects of Metoprolol, Diltiazem, and Pilocarpine on Hypoglycemia-Induced Prolongation of QT Interval

Metoprolol, pilocarpine, and diltiazem effectively prevent hypoglycemia-induced QTc prolongation in male rats.

RCTAnimal StudyRigorous Journal

2021·

1citation

·E. Cagiltay et al.

Effects of propranolol and metoprolol on glucose, cyclic AMP and insulin responses during pharmacologic hyperglucagonemia in hemodialysis patients.

Propranolol has a lower glucose response to glucagon in hemodialysis patients, while metoprolol improves this response after dialysis.

Non-RCT

1985·

8citations

·K. Pun et al.

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