met-oh-PROE-lol

Commonly used brand name(s)

In the U.S.

• Lopressor
• Toprol XL

Available Dosage Forms:

• Tablet, Extended Release
• Tablet

Therapeutic Class: Cardiovascular Agent

Pharmacologic Class: Beta-Adrenergic Blocker, Cardioselective

Uses For metoprolol

Metoprolol is used alone or together with other medicines to treat high blood pressure (hypertension). High blood pressure adds to the workload of the heart and arteries. If it continues for a long time, the heart and arteries may not function properly. This can damage the blood vessels of the brain, heart, and kidneys, resulting in a stroke, heart failure, or kidney failure. A lower blood pressure can reduce the risk of strokes and heart attacks.

Metoprolol is also used to treat severe chest pain (angina) and lowers the risk of repeated heart attacks. It is given to people who have already had a heart attack. In addition, metoprolol is used to treat patients with heart failure.

metoprolol is a beta-blocker. It works by affecting the response to nerve impulses in certain parts of the body, like the heart. As a result, the heart beats slower and decreases the blood pressure. When the blood pressure is lowered, the amount of blood and oxygen is increased to the heart.

metoprolol is available only with your doctor's prescription.

Before Using metoprolol

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For metoprolol, the following should be considered:

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to metoprolol or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

Appropriate studies have not been performed on the relationship of age to the effects of metoprolol tablets in the pediatric population. Safety and efficacy have not been established.

Appropriate studies have not been performed on the relationship of age to the effects of metoprolol extended-release tablets in children younger than 6 years of age. Safety and efficacy have not been established.

Geriatric

Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of metoprolol in the elderly. However, elderly patients are more likely to have age-related liver, kidney, or heart problems, which may require caution and an adjustment in the dose for patients receiving metoprolol.

Pregnancy

Pregnancy Category Explanation All Trimesters C Animal studies have shown an adverse effect and there are no adequate studies in pregnant women OR no animal studies have been conducted and there are no adequate studies in pregnant women.

Breast Feeding

Studies in women suggest that this medication poses minimal risk to the infant when used during breastfeeding.

Interactions with Medicines

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking metoprolol, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using metoprolol with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

• Albuterol
• Amiodarone
• Arformoterol
• Bambuterol
• Clenbuterol
• Clonidine
• Colterol
• Crizotinib
• Diltiazem
• Dronedarone
• Fenoldopam
• Fenoterol
• Fingolimod
• Formoterol
• Hexoprenaline
• Indacaterol
• Isoetharine
• Lacosamide
• Levalbuterol
• Lidocaine
• Metaproterenol
• Olodaterol
• Panobinostat
• Pirbuterol
• Procaterol
• Reproterol
• Ritodrine
• Rivastigmine
• Salmeterol
• Terbutaline
• Tretoquinol
• Tulobuterol
• Verapamil
• Vilanterol

Using metoprolol with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

• Acarbose
• Aceclofenac
• Acemetacin
• Acetyldigoxin
• Albiglutide
• Alfuzosin
• Alogliptin
• Amlodipine
• Amtolmetin Guacil
• Arbutamine
• Aspirin
• Bromfenac
• Bufexamac
• Bunazosin
• Canagliflozin
• Celecoxib
• Chlorpropamide
• Choline Salicylate
• Citalopram
• Clonixin
• Dapagliflozin
• Deslanoside
• Dexibuprofen
• Dexketoprofen
• Diclofenac
• Diflunisal
• Digitoxin
• Digoxin
• Dipyrone
• Doxazosin
• Dulaglutide
• Empagliflozin
• Etodolac
• Etofenamate
• Etoricoxib
• Exenatide
• Felbinac
• Felodipine
• Fenoprofen
• Fepradinol
• Feprazone
• Floctafenine
• Flufenamic Acid
• Flurbiprofen
• Glimepiride
• Glipizide
• Glyburide
• Ibuprofen
• Ibuprofen Lysine
• Indomethacin
• Insulin Aspart, Recombinant
• Insulin Degludec
• Insulin Detemir
• Insulin Glargine, Recombinant
• Insulin Glulisine
• Insulin Human Inhaled
• Insulin Human Isophane (NPH)
• Insulin Human Regular
• Insulin Lispro, Recombinant
• Ketoprofen
• Ketorolac
• Lacidipine
• Lercanidipine
• Linagliptin
• Liraglutide
• Lixisenatide
• Lornoxicam
• Loxoprofen
• Lumiracoxib
• Manidipine
• Meclofenamate
• Mefenamic Acid
• Meloxicam
• Metformin
• Metildigoxin
• Mibefradil
• Miglitol
• Mirabegron
• Morniflumate
• Moxisylyte
• Nabumetone
• Naproxen
• Nateglinide
• Nepafenac
• Nicardipine
• Nifedipine
• Niflumic Acid
• Nilvadipine
• Nimesulide
• Nimodipine
• Nisoldipine
• Nitrendipine
• Oxaprozin
• Oxyphenbutazone
• Parecoxib
• Phenelzine
• Phenobarbital
• Phenoxybenzamine
• Phentolamine
• Phenylbutazone
• Piketoprofen
• Pioglitazone
• Piroxicam
• Pramlintide
• Pranidipine
• Pranoprofen
• Prazosin
• Proglumetacin
• Propoxyphene
• Propyphenazone
• Proquazone
• Repaglinide
• Rifampin
• Rifapentine
• Rofecoxib
• Rosiglitazone
• Salicylic Acid
• Salsalate
• Saxagliptin
• Sitagliptin
• Sodium Salicylate
• St John's Wort
• Sulindac
• Tamsulosin
• Telithromycin
• Tenoxicam
• Terazosin
• Tiaprofenic Acid
• Tolazamide
• Tolbutamide
• Tolfenamic Acid
• Tolmetin
• Trimazosin
• Urapidil
• Valdecoxib
• Venlafaxine
• Vildagliptin

Interactions with Food/Tobacco/Alcohol

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Other Medical Problems

The presence of other medical problems may affect the use of metoprolol. Make sure you tell your doctor if you have any other medical problems, especially:

• Angina (chest pain) or
• Hypotension (low blood pressure) or
• Ischemic heart disease or
• Lung disease (eg, asthma, bronchitis, emphysema) or
• Pheochromocytoma (adrenal gland tumor)—Use with caution. May make these conditions worse.

• Blood circulation problems, severe or
• Bradycardia (slow heartbeat) or
• Cardiogenic shock (shock caused by heart attack) or
• Heart block or
• Heart failure, severe or
• Peripheral vascular disorders (clogged blood vessels) or
• Sick-sinus syndrome (heart rhythm problem)—Should not be used in patients with these conditions.

• Diabetes or
• Hyperthyroidism (overactive thyroid) or
• Hypoglycemia (low blood sugar)—May cover up some of the symptoms of these diseases, such as a fast heartbeat.

• Liver disease—Use with caution. The effects may be increased because of slower removal of the medicine from the body.

Proper Use of metoprolol

Take metoprolol only as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered. Your dose may need to be changed several times in order to find out what works best for you.

In addition to the use of metoprolol, treatment for your high blood pressure may include weight control and changes in the types of foods you eat, especially foods high in sodium (salt). Your doctor will tell you which of these are most important for you. You should check with your doctor before changing your diet.

Many patients who have high blood pressure will not notice any signs of the problem. In fact, many patients feel normal. It is very important that you take your medicine exactly as directed and that you keep your appointments with your doctor even if you feel well.

Remember that metoprolol will not cure your high blood pressure, but it does help control it. You must continue to take it as directed if you expect to lower your blood pressure and keep it down. You may have to take high blood pressure medicine for the rest of your life. If high blood pressure is not treated, it can cause serious problems such as heart failure, blood vessel disease, strokes, or kidney disease.

Take metoprolol with a meal or just after you eat. You may break the extended-release tablet into two pieces, but swallow the two pieces whole and do not crush or chew them.

Swallow the tablet whole with a glass of water. Do not crush, break, or chew it.

Dosing

The dose of metoprolol will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of metoprolol. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

• For acute heart attack or heart failure:
  • For oral dosage form (extended-release tablets):
    • Adults—At first, 25 milligrams (mg) once a day for 2 weeks. In patients with severe heart failure, the starting dose is 12.5 mg once a day. Your doctor may adjust your dose as needed.
    • Children—Use and dose must be determined by your doctor.
  • For oral dosage form (tablets):
    • Adults—At first, 50 milligrams (mg) every 6 hours for 2 days. Then, 100 mg two times a day. The medicine will be started in the hospital.
    • Children—Use and dose must be determined by your doctor.
• For chest pain:
  • For oral dosage form (extended-release tablets):
    • Adults—At first, 100 milligrams (mg) once a day. Your doctor may adjust your dose if needed. However, the dose is usually not more than 400 mg per day.
    • Children—Use and dose must be determined by your doctor.
  • For oral dosage form (tablets):
    • Adults—At first, 100 milligrams (mg) per day, given in two divided doses. Your doctor may adjust your dose if needed. However, the dose is usually not more than 400 mg per day.
    • Children—Use and dose must be determined by your doctor.
• For high blood pressure:
  • For oral dosage form (extended-release tablets):
    • Adults—At first, 25 to 100 milligrams (mg) once a day. Your doctor may adjust your dose if needed. However, the dose is usually not more than 400 mg per day.
    • Children 6 years of age and older—Dose is based on body weight and must be determined by your doctor. The dose is usually 1 milligram (mg) per kilogram (kg) of body weight per day, given as a single dose. The first dose should not be more than 50 mg per day.
    • Children younger than 6 years of age—Use and dose must be determined by your doctor.
  • For oral dosage form (tablets):
    • Adults—At first, 100 milligrams (mg) per day, given as a single dose or in divided doses. Your doctor may adjust your dose if needed. However, the dose is usually not more than 450 mg per day.
    • Children—Use and dose must be determined by your doctor. .

Missed Dose

If you miss a dose of metoprolol, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Ask your healthcare professional how you should dispose of any medicine you do not use.

Precautions While Using metoprolol

It is very important that your doctor check your progress at regular visits to make sure metoprolol is working properly and to check for unwanted effects.

Metoprolol may worsen the symptoms of heart failure in some patients. Check with your doctor right away if you are having chest pain or discomfort, dilated neck veins, extreme fatigue, irregular breathing, an irregular heartbeat, shortness of breath, swelling of the face, fingers, feet, or lower legs, weight gain, or wheezing.

Do not suddenly stop taking metoprolol without first checking with your doctor. Your doctor may want you to gradually reduce the amount you are taking before stopping it completely. Some conditions may become worse when the medicine is stopped suddenly, which can be dangerous.

metoprolol may cause changes in blood sugar levels. Also, metoprolol may cover up the symptoms of low blood sugar, such as a rapid pulse rate. Check with your doctor if you notice a change in your normal symptoms or a change in the results of your blood or urine sugar tests.

Make sure any doctor or dentist who treats you knows that you are using metoprolol. You may need to stop using metoprolol several days before having surgery.

metoprolol may cause some people to become less alert than they are normally. If this side effect occurs, do not drive, use machines, or do anything else that could be dangerous if you are not alert.

Dizziness, lightheadedness, or even fainting may occur when you get up suddenly from a lying or sitting position. Getting up slowly may help lessen this problem. Also, lying down for a while may relieve the dizziness or lightheadedness.

Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines for appetite control, asthma, colds, cough, hay fever, or sinus problems, since they may increase your blood pressure.

metoprolol Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

More common

• Blurred vision
• chest pain or discomfort
• confusion
• dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
• shortness of breath
• slow or irregular heartbeat
• sweating
• unusual tiredness or weakness

Less common

• Bloating or swelling of the face, arms, hands, lower legs, or feet
• cough
• decreased urine output
• difficult or labored breathing
• difficulty with speaking
• dilated neck veins
• disturbed color perception
• double vision
• extreme fatigue
• fast, pounding, or racing heartbeat or pulse
• halos around lights
• headache
• inability to move the arms, legs, or facial muscles
• inability to speak
• irregular breathing
• loss of vision
• night blindness
• noisy breathing
• overbright appearance of lights
• pain, tension, and weakness upon walking that subsides during periods of rest
• paleness or cold feeling in the fingertips and toes
• rapid weight gain
• seeing, hearing, or feeling things that are not there
• short-term memory loss
• slow speech
• swelling of the face, fingers, feet, or lower legs
• tightness in the chest
• tingling of the hands or feet
• tingling or pain in the fingers or toes when exposed to cold
• troubled breathing
• tunnel vision
• unusual weight gain or loss

Rare

• Bluish color skin of the fingers or toes
• chills
• clay-colored stools
• continuing loss of appetite
• continuing or severe abdominal or stomach pain
• continuing or severe nausea and vomiting
• dark urine
• difficulty with moving
• fever
• general tiredness and weakness
• hoarseness
• increased frequency of urination
• itching skin
• light-colored stools
• lower back or side pain
• muscle pain or stiffness
• numbness of the fingers or toes
• pain, swelling, or redness in the joints
• rash
• sore throat
• sores, ulcers, or white spots on the lips or in the mouth
• unpleasant breath odor
• unusual bleeding or bruising
• upper right abdominal or stomach pain
• vomiting of blood
• weakness
• yellow eyes and skin

Incidence not known

• Black, tarry stools
• bleeding gums
• blood in the urine or stools
• burning, crawling, itching, numbness, prickling, "pins and needles", or tingling feelings
• cool, sweaty skin
• pinpoint red spots on the skin

Get emergency help immediately if any of the following symptoms of overdose occur:

Symptoms of overdose

• Bluish color of the fingernails, lips, skin, palms, or nail beds
• change in consciousness
• loss of consciousness
• no blood pressure or pulse
• stopping of heart
• unconsciousness
• very drowsy or sleepy

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

Less common

• Belching
• bloated
• decreased interest in sexual intercourse
• difficulty having a bowel movement (stool)
• discouragement
• dry mouth
• excess air or gas in stomach or intestines
• feeling of constant movement of self or surroundings
• feeling of indigestion
• feeling sad or empty
• full feeling
• inability to have or keep an erection
• irritability
• loss in sexual ability, desire, drive, or performance
• loss of interest or pleasure
• nightmares
• pain in the chest below the breastbone
• passing gas
• redness or other discoloration of the skin
• runny nose
• sensation of spinning
• sneezing
• stuffy nose
• tiredness
• trouble concentrating
• trouble sleeping

Rare

• Bone pain
• continuing ringing or buzzing or other unexplained noise in the ears
• dry eyes
• hair loss or thinning of the hair
• hearing loss
• increased sensitivity of the skin to sunlight
• pain of penis on erection
• severe sunburn

Incidence not known

• Change in taste or bad, unusual, or unpleasant (after) taste
• fear or nervousness
• hives or welts

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

See also: Side effects (in more detail)

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Usual Adult Dose for Angina Pectoris Prophylaxis

Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 450 mg/day.
Extended release may be used at the same total daily dose given once a day.

Usual Adult Dose for Hypertension

Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 450 mg/day.
Extended release may be used at the same total daily dose given once a day.

Usual Adult Dose for Supraventricular Tachycardia

Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 450 mg/day.
Extended release may be used at the same total daily dose given once a day.

Usual Adult Dose for Angina Pectoris

Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 400 mg/day.
Extended release may be used at the same total daily dose given once a day.

Usual Adult Dose for Myocardial Infarction

Early treatment:
IV: 3 bolus injections of 5 mg of metoprolol given at 2 minute intervals.
Oral: In patients who tolerate the full IV dose (15 mg), metoprolol tablets, 50 mg every 6 hours, should be initiated 15 minutes after the last IV dose and continued for 48 hours. Maintenance dose: 100 mg orally twice a day.
Patients who appear not to tolerate the full IV dose should be started on metoprolol tablets at 25 mg or 50 mg every 6 hours 15 minutes after the last intravenous dose or as soon as their clinical condition allows.

Late treatment:
Oral: 100 mg orally twice a day.
Patients with contraindications to treatment during the early phase of suspected or definite myocardial infarction, patients who appear not to tolerate the full early treatment, and patients in whom the physician wishes to delay therapy for any other reason should be started on metoprolol tablets as soon as their clinical condition allows.

Usual Adult Dose for Congestive Heart Failure

Initial dose: 25 mg once daily (of the XL formulation) for two weeks in patients with NYHA class II heart failure and 12.5 mg once daily (of the XL formulation) in patients with more severe heart failure.
Maintenance dose: This dosage should then be doubled every two weeks to the highest dosage level tolerated or up to 200 mg.

If transient worsening of heart failure occurs, it may be treated with increased doses of diuretics, and it may also be necessary to lower the dose or temporarily discontinue treatment. The dose should not be increased until symptoms of worsening heart failure stabilize.

Initial difficulty with titration should not preclude later attempts to institute therapy. If heart failure patients experience symptomatic bradycardia, the dose of metoprolol should be reduced.

Usual Pediatric Dose for Hypertension

Immediate release:
1 to 17 years:
Initial dose: 1 to 2 mg/kg/day, administered in 2 divided doses. Dosage should be adjusted based on patient response.
Maximum dose: 6 mg/kg/day (less than or equal to 200 mg/day)

Extended release:
6 to 16 years:
Initial dose: 1 mg/kg orally once daily (not to exceed 50 mg once daily). The minimum available dose is one half of the 25 mg tablet.
Maintenance dose: Dosage should be adjusted according to blood pressure response. Doses above 2 mg/kg (or in excess of 200 mg) once daily have not been studied.

Renal Dose Adjustments

No adjustment is usually recommended in patients with chronic renal failure.

Liver Dose Adjustments

Metoprolol should be used with caution in patients with hepatic disease.

Dose Adjustments

The dosage may be increased at weekly (or longer) intervals until optimum blood pressure reduction is achieved or there is pronounced slowing of the heart rate. In general, the maximum effect of any given dosage level will be apparent after 1 week of therapy.

While once daily dosing is effective and can maintain a reduction in blood pressure throughout the day, lower doses (especially 100 mg) may not maintain a full effect at the end of the 24-hour period, and larger or more frequent daily doses may be required. This can be evaluated by measuring blood pressure near the end of the dosing interval to determine whether satisfactory control is being maintained throughout the day.

In general, a lower initial starting dose should be used in elderly patients given their greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

Because metoprolol is metabolized by the liver, metoprolol blood levels are likely to increase substantially with poor hepatic function. Therefore, therapy should be initiated at doses lower than those recommended for a given indication; and doses should be increased gradually in patients with impaired hepatic function.

Precautions

Safety and effectiveness of metoprolol immediate release has not been established in pediatric patients less than 2 years of age. Safety and effectiveness of metoprolol controlled release has not been established in pediatric patients less than 6 years of age.

Dialysis

A supplemental dose should be administered after hemodialysis. No supplemental dose is needed with peritoneal dialysis.

Other Comments

Metoprolol should be taken with or immediately following meals.
Doses above 450 mg per day have not been studied for hypertension.
Myocardial Infarction therapy should be continued for at least 3 months. Although the efficacy of metoprolol beyond 3 months has not been conclusively established, data from studies with other beta blockers suggest that treatment should be continued for 1 to 3 years.

Doses above 400 mg per day have not been studied for angina pectoris.

Compared with Caucasian patients, Black patients have a reduced blood pressure response to monotherapy with beta-blockers; however, the reduced response is largely eliminated if combination therapy that includes an adequate dose of a diuretic is instituted.

Metoprolol Side Effects