Prevention of MI and decreased mortality in patients with recent MI.
Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathic origin (may be used with ACE inhibitors, diuretics and/or digoxin; Toprol XL only).
Unlabeled Use(s):
Ventricular arrhythmias/tachycardia.
Migraine prophylaxis.
Tremors.
Aggressive behavior.
Drug-induced akathisia.
Anxiety.
Action
Blocks stimulation of beta1 (myocardial)-adrenergic receptors. Does not usually affect beta2 (pulmonary, vascular, uterine)-adrenergic receptor sites.
Therapeutic Effect(s):
Decreased BP and heart rate.
Decreased frequency of attacks of angina pectoris.
Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure.
Pharmacokinetics
Absorption: Well absorbed after oral administration.
Distribution: Crosses the blood-brain barrier, crosses the placenta; small amounts enter breast milk.
Metabolism and Excretion: Mostly metabolized by the liver (primarily by CYP2D6; the CYP2D6 enzyme system exhibits genetic polymorphism); ~7% of population may be poor metabolizers and may have significantly ↑ metoprolol concentrations and an ↑ risk of adverse effects.
Half-life: 3–7 hr.
TIME/ACTION PROFILE (cardiovascular effects)
ROUTE
ONSET
PEAK
DURATION
PO†
15 min
unknown
6–12 hr
PO–ER
unknown
6–12 hr
24 hr
IV
immediate
20 min
5–8 hr
†Maximal effects on BP (chronic therapy) may not occur for 1 wk. Hypotensive effects may persist for up to 4 wk after discontinuation.
Contraindication/Precautions
Contraindicated in:
Uncompensated HF;
Pulmonary edema;
Cardiogenic shock;
Bradycardia, heart block, or sick sinus syndrome (in absence of a pacemaker).
Use Cautiously in:
Renal impairment;
Hepatic impairment;
Pulmonary disease (including asthma; beta1 selectivity may be lost at higher doses);
Diabetes mellitus (may mask signs of hypoglycemia);
Thyrotoxicosis (may mask symptoms);
Patients with a history of severe allergic reactions (intensity of reactions may be ↑);
Untreated pheochromocytoma (initiate only after alpha blocker therapy started);
OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk; crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant; may result in bradycardia, constipation, diarrhea, and dry mouth/skin/eyes in infant, especially in mothers who are CYP2D6 poor metabolizers.
Pedi: Safety and effectiveness not established in children <18 yr (tablets, extended-release tablets, and injection) or <6 yr (extended-release capsules);
Geri: Older adults may have ↑ sensitivity to beta blockers; initial dose ↓ recommended.
May ↓ the beneficial beta1 -cardiovascular effects of dopamine or dobutamine.
Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).
Route/Dosage
When switching from immediate-release to extended-release product, the same total daily dose can be used
PO (Adults): Hypertension/angina– 25–100 mg/day as a single dose initially or 2 divided doses; may be ↑ every 7 days as needed up to 450 mg/day (immediate-release) or 400 mg/day (extended-release) (for angina, give in divided doses). Extended-release products are given once daily. MI– 25–50 mg (starting 15 min after last IV dose) every 6 hr for 48 hr, then 100 mg twice daily. Heart failure– 12.5–25 mg once daily (of extended-release), can be doubled every 2 wk up to 200 mg/day. Migraine prevention– 50–100 mg 2–4 times daily (unlabeled).
IV (Adults): MI– 5 mg every 2 min for 3 doses, followed by oral dosing.
PO (Children ≥6 yr): Hypertension– 1 mg/kg once daily (extended-release capsules); may be titrated, as needed (not to exceed 50 mg/day).
In Combination with: hydrochlorothiazide (Dutoprol, Lopressor HCT). See combination drugs.
Assessment
Monitor BP, ECG, and pulse frequently during dose adjustment and periodically during therapy.
Monitor frequency of prescription refills to determine compliance.
Monitor vital signs and ECG every 5–15 min during and for several hrs after parenteral administration. If heart rate <40 bpm, especially if cardiac output is also decreased, administer atropine 0.25–0.5 mg IV.
Monitor intake and output ratios and daily weights. Assess routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention).
Angina: Assess frequency and characteristics of anginal attacks periodically during therapy.
Lab Test Considerations:
May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
May cause ↑ ANA titers.
May cause ↑ in blood glucose levels.
May cause ↑ serum alkaline phosphatase, LDH, AST, and ALT levels.
Implementation
High Alert: IV vasoactive medications are inherently dangerous. Before administering intravenously, have second practitioner independently check original order and dose calculations.
High Alert: Do not confuse Toprol-XL (metoprolol succinate) with Topamax (topiramate). Do not confuse Lopressor (metoprolol tartrate) with Lyrica (pregabalin). Do not confuse metoprolol tartrate with metoprolol succinate.
PO
Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify health care professional.
Administer metoprolol with meals or directly after eating.
DNC: Extended-release tablets may be broken in half; do not crush or chew.
Swallow Kapspargo Sprinkle whole. If unable to swallow a capsule, may be opened and contents sprinkled over soft food (applesauce, pudding, yogurt). Swallow contents of capsule along with a small amount (tsp) of soft food. Swallow drug/food mixture within 60 min; do not store for future use. May also be administered via NG tube by opening and adding capsule contents to an all plastic oral tip syringe and adding 15 mL of water. Gently shake syringe for about 10 sec. Promptly administer through a 12 French or larger NG tube. Rinse with additional water to ensure no granules are left in syringe.
IV Administration
IV Push: Diluent: Administer undiluted. Concentration: 1 mg/mL.
Rate: Administer over 1 min.
Y-Site Compatibility:
acetaminophen
acyclovir
albumin, human
MORE...
alemtuzumab
alfentanil
amikacin
aminocaproic acid
aminophylline
amiodarone
amphotericin B liposome
anidulafungin
argatroban
arsenic trioxide
ascorbic acid
atropine
aztreonam
benztropine
bivalirudin
bleomycin
bumetanide
buprenorphine
butorphanol
calcium chloride
calcium gluconate
cangrelor
carboplatin
carmustine
caspofungin
cefazolin
cefepime
cefotaxime
cefotetan
cefoxitin
ceftaroline
ceftazidime
ceftriaxone
cefuroxime
chloramphenicol
chlorpromazine
ciprofloxacin
cisplatin
clindamycin
cyanocobalamin
cyclophosphamide
cyclosporine
cytarabine
dacarbazine
dactinomycin
daptomycin
daunorubicin hydrochloride
dexamethasone
dexmedetomidine
dexrazoxane
digoxin
diltiazem
diphenhydramine
dobutamine
docetaxel
dopamine
doxorubicin hydrochloride
doxorubicin liposomal
doxycycline
enalaprilat
ephedrine
epinephrine
epirubicin
epoetin alfa
eptifibatide
erythromycin
esmolol
esomeprazole
etoposide
etoposide phosphate
famotidine
fenoldopam
fentanyl
fluconazole
fludarabine
fluorouracil
folic acid
foscarnet
fosphenytoin
furosemide
ganciclovir
gemcitabine
gentamicin
glycopyrrolate
granisetron
heparin
hetastarch
hydrocortisone
hydromorphone
ibuprofen
idarubicin
ifosfamide
imipenem/cilastatin
indomethacin
insulin, regular
irinotecan
isoproterenol
ketorolac
labetalol
lactated Ringer's
leucovorin calcium
levofloxacin
levothyroxine
linezolid
lorazepam
magnesium sulfate
mannitol
meperidine
meropenem
mesna
methadone
methotrexate
methylprednisolone
metoclopramide
metronidazole
midazolam
milrinone
mitomycin
mitoxantrone
morphine
moxifloxacin
multivitamins
mycophenolate
nafcillin
nalbuphine
naloxone
nicardipine
nitroprusside
norepinephrine
0.9% NaCl
octreotide
ondansetron
oxacillin
oxaliplatin
oxytocin
paclitaxel
palonosetron
pamidronate
pancuronium
papaverine
pemetrexed
penicillin G
pentamidine
pentobarbital
phenobarbital
phentolamine
phenylephrine
phytonadione
piperacillin/tazobactam
potassium acetate
potassium chloride
procainamide
prochlorperazine
promethazine
propranolol
protamine
pyridoxine
quinupristin/dalfopristin
rocuronium
sodium bicarbonate
succinylcholine
sufentanil
tacrolimus
theophylline
thiamine
thiotepa
tigecycline
tirofiban
tobramycin
vancomycin
vasopressin
vecuronium
verapamil
vinblastine
vincristine
vinorelbine
voriconazole
zoledronic acid
Y-Site Incompatibility:
allopurinol
amphotericin B deoxycholate
amphotericin B lipid complex
MORE...
dantrolene
diazepam
gemtuzumab ozogamicin
pantoprazole
phenytoin
trimethoprim/sulfamethoxazole
Patient/Family Teaching
Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 8 hr before next dose. Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia.
Teach patient and family how to check pulse daily and BP biweekly and to report significant changes to health care professional.
May cause drowsiness. Caution patient to avoid driving or other activities that require alertness until response to the drug is known.
Advise patient to change positions slowly to minimize orthostatic hypotension.
Caution patient that this medication may increase sensitivity to cold.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any Rx, OTC, or herbal products, especially cold preparations, concurrently with this medication. Patients on antihypertensive therapy should also avoid excessive amounts of coffee, tea, and cola.
Diabetics should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication does not block sweating as a sign of hypoglycemia.
Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
Instruct patient to inform health care professional of medication regimen before treatment or surgery.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected, or if breast feeding. Monitor neonates of women taking metoprolol for symptoms of hypotension, bradycardia, hypoglycemia, and respiratory depression and manage accordingly. Monitor breast-fed infants for bradycardia, dry mouth, skin or eyes, and diarrhea or constipation.
Advise patient to carry identification describing disease process and medication regimen at all times.
Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.
Evaluation/Desired Outcomes
Decrease in BP.
Reduction in frequency of anginal attacks.
Increase in activity tolerance.
Prevention of MI.
metoprolol is a sample topic from the Davis's Drug Guide.
Davis’s Drug Guide for Nurses App + Web from F.A. Davis and Unbound Medicine covers 5000+ trade name and generic drugs. Includes App for iPhone, iPad, and Android smartphone + tablet. Handbook covers dosage, side effects, interactions, uses. Davis Drug Guide PDF. Complete Product Information.