Metoprolol withdrawal effects
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Metoprolol Withdrawal Effects: Cardiovascular and Symptom Rebound
Heart Rate and Beta-Adrenergic Sensitivity After Metoprolol Withdrawal
Abrupt withdrawal of metoprolol can cause a significant rebound increase in heart rate and cardiac sensitivity to beta-adrenergic stimulation. Studies show that after stopping metoprolol, patients experienced a 15% rise in resting heart rate and a 52% increase in cardiac chronotropic sensitivity to isoproterenol within 2 to 8 days. These changes indicate a temporary increase in the heart’s responsiveness to stress hormones, which is known as beta-adrenergic receptor hypersensitivity. This effect is more pronounced with metoprolol compared to some other beta-blockers like pindolol, which shows less risk of such rebound phenomena 1236.
Blood Pressure and Arrhythmias
A transient increase in blood pressure can occur in some patients after stopping metoprolol, but this is not universal. Importantly, while heart rate increases are common, studies using Holter monitoring did not find a significant increase in arrhythmias immediately after withdrawal in otherwise healthy patients 1236. However, in patients with ischemic heart disease, withdrawal can unmask or worsen cardiac symptoms, sometimes requiring the medication to be restarted 45.
Withdrawal Symptoms
Some patients report withdrawal-like symptoms such as headache, palpitations, and tremor after stopping metoprolol. These symptoms are less common than with propranolol but more frequent than with pindolol. The severity and duration of withdrawal symptoms seem to be related to the potency and duration of beta-blockade 36.
Gradual vs. Abrupt Withdrawal
Gradual reduction of metoprolol dose before stopping can reduce, but not completely prevent, the rebound effects on heart rate and beta-adrenergic sensitivity. Even with a slow taper, some patients still experience increased heart rate and symptoms, especially those with underlying heart disease 145.
Effects on Cardiac Function in Heart Disease
In patients with ischemic heart disease or dilated cardiomyopathy, stopping metoprolol can lead to a rapid increase in heart rate, worsening of symptoms, and a decrease in left ventricular function. Some patients may need to restart metoprolol due to disabling symptoms or deterioration in heart function. When metoprolol is reintroduced, heart function often improves again 459.
Mental and Physical Stress Responses
After withdrawal, there is a rebound increase in heart rate and cardiac response to physical stress, but not necessarily to mental stress. This suggests that different body systems recover at different rates after stopping metoprolol 47.
Other Physiological Effects
Metoprolol withdrawal can also affect other body systems. For example, stopping the drug can increase saliva production and change the composition of saliva, with these effects reversing when the drug is restarted . Changes in blood lipids after withdrawal are minor and not significantly different from placebo in patients who tolerate stopping the drug .
Conclusion
Metoprolol withdrawal, especially if abrupt, can cause a temporary increase in heart rate, beta-adrenergic sensitivity, and sometimes blood pressure, along with symptoms like palpitations and headache. These effects are more pronounced in patients with heart disease and can be reduced, but not always prevented, by gradual dose reduction. Careful monitoring and a slow taper are recommended, particularly for patients with underlying cardiac conditions.
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