Metoprolol: different doses for different circumstances

According to the American Heart Association, nearly half of adults in the United States live with high blood pressure (AHA, 2017). 

High blood pressure is a condition that damages some of the most vital parts of the body, including the brain, heart, and blood vessels (AHA, 2016). With regard to the heart, high blood pressure can lead to heart attacks, heart failure, and heart disease.

In addition to lifestyle changes such as a healthy diet and regular exercise, taking medication is one of the most effective ways to control blood pressure. A drug that's commonly prescribed, alone or in combination with other medicines, is a beta-blocker called metoprolol.

Like other beta-blockers, metoprolol is designed to slow down the heart rate, improve blood flow to the heart, and decrease overall blood pressure. In addition to treating hypertension, metoprolol is used to prevent severe chest pain (angina), improve survival after a heart attack, and treat people with heart failure.

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Metoprolol comes in three forms:

• An immediate-release tablet (metoprolol tartrate)

• An extended-release tablet (metoprolol succinate)

• An injectable form (metoprolol tartrate)

The immediate-release tablet (metoprolol tartrate) is usually taken once or twice per day with meals or following meals. In contrast, the extended-release tablet (metoprolol succinate) is a long-acting version taken just once per day. The injectable form (metoprolol tartrate) is administered by a healthcare provider directly into a person's vein (intravenous).

Another difference between metoprolol tartrate (brand name Lopressor) and metoprolol succinate (brand name Toprol-XL) is the type of salt they contain. The regular tablet contains tartrate, while extended-release contains succinate. Apo-Metoprolol, Betaloc, Novo-Metoprol, and Minimax are other brand names for the drug.

Both metoprolol tartrate (brand name Lopressor) and metoprolol succinate (brand name Toprol-XL) treat high blood pressure and chest pain. However, providers only use metoprolol tartrate in the first 24 hours after a heart attack (UpToDate, n.d.). 

Regardless of the type of metoprolol, the dose varies, so it is imperative to take the medication exactly as prescribed by your healthcare provider. The exact dose largely depends on:

• The condition being treated

• Other medical conditions 

• Additional medications you are taking

• Response to the medication 

• Age

If you currently have any of the following conditions, your healthcare provider may consider starting you on a lower dose or alternative medication (UpToDate, n.d.):

• Previous allergic reaction to metoprolol

• Low blood pressure (less than 90/60 mmHg)

• Lung disease, like severe asthma or other causes of bronchospasm

• An overactive thyroid (hyperthyroidism)

• Raynaud's disease

• Pheochromocytoma (untreated)

• Diabetes

• Pregnancy

Also important to note, both forms of metoprolol share similar drug interactions. If you are taking any of the medications listed below, there could be a chance that taking combining the two will lead to an adverse reaction (DailyMed, 2018). 

• Heart and blood pressure medications: propafenone, other beta-blocking agents (like propranolol), reserpine, calcium-channel blockers (like diltiazem), hydralazine

• Mental health medications: bupropion (brand names Aplenzin, Forfivo, Wellbutrin, Zyban), fluoxetine (brand names Prozac, Sarafem, Selfemra; see Important Safety Information), paroxetine (brand names Brisdelle, Paxil, Pexeva; see Important Safety Information), clonidine (brand name Catapres), thioridazine

• Heart and blood pressure medications: propafenone, other beta-blocking agents (like propranolol), reserpine, calcium-channel blockers (like diltiazem), hydralazine

• Other medications: antiretroviral drugs like ritonavir (brand name Norvir), antihistamine drugs like diphenhydramine (brand name Benadryl), antimalarial drugs like quinidine, antifungal drugs like terbinafine (brand name Lamisil)

Your healthcare provider will work with you to determine the best metoprolol dose for you. The doses listed below are only suggested ranges.

Hypertension

When left untreated, high blood pressure can cause serious health complications and increase the risk of heart disease, stroke, and even death. Both metoprolol tartrate (brand name Lopressor) and metoprolol succinate (brand name Toprol-XL) tablets treat hypertension (UpToDate, n.d.). 

The usual dosage range of the immediate-release tablets (metoprolol tartrate) is 100 mg to 200 mg orally in two divided doses per day. Extended-release tablets (metoprolol succinate) dosages usually range from 50 mg to 200 mg once daily (UpToDate, n.d.). 

Angina Pectoris

Angina pectoris refers to chest pain that occurs as a symptom of coronary heart disease or coronary artery disease. It feels like pressure, tightness, or heaviness in the chest and happens when the heart muscle doesn't get as much blood as it needs. 

Similar to hypertension, metoprolol succinate and metoprolol tartrate are both suitable options for treating angina pectoris. The dosages range from 50 mg to 100 mg twice daily for metoprolol tartrate and 100 to 400 mg per day for metoprolol succinate (UpToDate, n.d.)

Myocardial Infarction 

Also known as a heart attack, a myocardial infarction occurs when the blood cannot properly flow to the heart muscle.

Early treatment for an acute myocardial infarction may include 5 mg IV of metoprolol tartrate every 5 minutes as tolerated for three doses. From there, oral metoprolol tartrate 12.5 mg to 50 mg every 6-12 hours may be used. Once you are stable and can leave the hospital, you may be given metoprolol succinate pills, 25 mg to 50 mg daily (UpToDate, n.d.).

Congestive Heart Failure

Congestive heart failure is a chronic condition where the heart doesn't pump blood as well as it should, resulting in shortness of breath, fatigue, swollen legs, and rapid heartbeat. 

In stable patients, metoprolol succinate tablets may be prescribed in 12.5 mg to 25 mg daily up to a maximum dose of 200 mg per day (UpToDate, n.d.).

Pediatric hypertension

A child or adolescent is diagnosed with hypertension when their average blood pressure is the same or higher than the 95th percentile for their age, sex, and height. Beta-blockers like metoprolol are not the first class of drugs that the healthcare provider will reach for when treating kids with high blood pressure. However, it may be used in certain situations.

For children six years and older, the standard initial dose of metoprolol succinate is 1 mg/kg once per day and may be gradually increased until they reach the maximum daily dose of 200 mg daily (UpToDate, n.d.). If using metoprolol tartrate, the dose usually starts around 0.5 mg to 1 mg/kg twice daily; this can be increased as tolerated up to a maximum of 200 mg per day. (UpToDate, n.d.). 

Most of the adverse effects of metoprolol are mild and transient. For example, when first starting metoprolol, people might experience dizziness or headaches. While this might be an innocuous reaction to a new medication, metoprolol succinate (brand name Toprol-XL) and metoprolol tartrate (brand name Lopressor) do carry a black-box warning, the most serious warning from the FDA (FDA, 2006; FDA, 2008). The label states that sudden discontinuation of the medication may exacerbate chest pain or cause a heart attack, with a higher risk among people with heart disease (FDA, 2008).

Other side effects of metoprolol include tiredness, depression, diarrhea, shortness of breath, wheezing, nausea, dry mouth, gastric pain, hives, weight gain, and constipation. More serious, yet rare, side effects are heart block, low blood pressure, slow heart rate (bradycardia), worsening asthma or other lung condition, worsening of heart failure, and masking of low blood sugar (hypoglycemic) response (DailyMed, 2018).

Both forms of metoprolol are considered pregnancy Category C and are present in breast milk. There is not enough data to indicate whether it is safe to take during pregnancy or nursing, so talk to your healthcare provider.

Because the metoprolol comes in different forms and is approved for various uses, it's imperative to work with your healthcare provider to find the right dose for you. There are countless articles about metoprolol on the internet but always turn to your healthcare provider for medical advice, especially when it comes to prescription drugs.

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Current version

October 05, 2020

Written by

Alexandria Bachert

Fact checked by

Chimene Richa, MD

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About the medical reviewer

Chimene Richa, MD

Dr. Richa is a board-certified Ophthalmologist and medical writer for Ro.