Cardioselective beta-1 adrenoceptor blocker
Metoprolol (succinate / tartrate)
Selective beta-1 blockade reduces heart rate, contractility and AV conduction, lowering myocardial oxygen demand; in heart failure it attenuates chronic sympathetic activation and remodelling.
Brands
Betaloc · Lopressor · Metolar XR
Adult dosing
Maximum 200 mg/day| Indication | Dose | Route | Frequency |
|---|---|---|---|
| Post-myocardial infarction, tartrate | 25-50 mgMax 200 mg/day | Oral | Twice daily, titrated |
| Heart failure, succinate (modified release) | 12.5-25 mgMax 200 mg once daily | Oral | Once daily, doubled every 2 weeks as tolerated |
| Rate control in atrial fibrillation | 2.5-5 mgAvoid intravenous use in decompensated failure | IV over 2 minutes | Repeat up to 3 doses |
Older adults: Start at half the usual dose; watch for bradycardia and postural symptoms.
Paediatric dosing
Always confirm the weight and the local paediatric formulary| Indication | Dose | Route | Frequency |
|---|---|---|---|
| Hypertension, over 6 years | 0.5-1 mg/kg/dayMax 50 mg/day initially, 200 mg/day overall | Oral | Once or twice daily |
| Under 6 years | Specialist use only | — | — |
Renal adjustment
Move the slider to the patient's eGFRNo adjustment — hepatic clearance
- eGFR ≥ 15No adjustment — hepatic clearance
- eGFR < 15 or dialysisNo adjustment; titrate to heart rate and blood pressure
Hepatic adjustment
- Significant impairmentStart low and titrate slowly — CYP2D6 metabolism
Practical notes
The things that go wrong at the bedside- Never start or up-titrate during acute decompensation of heart failure.
- CYP2D6 poor metabolisers, and patients on fluoxetine or paroxetine, get an exaggerated effect.
DrZep structured dosing table (demo dataset, formulary-aligned) · DrZep. Confirm every dose against your local formulary and the patient's weight, renal function and comorbidities.
Indications
- Post-myocardial infarction and chronic coronary syndrome
- Heart failure with reduced ejection fraction (succinate, extended release)
- Rate control in atrial fibrillation
- Hypertension
- Migraine prophylaxis and thyrotoxicosis symptom control
Dosing summary
- HFrEF (succinate ER)
- Start 12.5-25 mg once daily; double every 2 weeks to a target of 200 mg once daily
- Post-MI (tartrate)
- 25-50 mg twice daily, titrated
- Rate control
- 25-100 mg twice daily (tartrate)
- Intravenous (acute)
- 2.5-5 mg over 2 min, repeat to a maximum of 15 mg with monitoring
Organ adjustment
Renal
- All stages
- No adjustment (hepatic metabolism)
Hepatic
- Cirrhosis
- Reduce dose — extensive first-pass metabolism
Monitoring
- 1Heart rate and blood pressure at each titration
- 2Symptoms of congestion when up-titrating in heart failure
- 3Glucose awareness in insulin-treated diabetes
Contraindications & cautions
Do not use / use with care
- Second- or third-degree AV block without a pacemaker
- Cardiogenic shock or decompensated heart failure requiring inotropes
- Severe bradycardia or sinus node dysfunction
- Severe untreated asthma with bronchospasm
- Untreated phaeochromocytoma
Pregnancy & lactation
- Pregnancy
- Used when required (e.g. arrhythmia, hypertension); monitor for fetal growth restriction and neonatal bradycardia and hypoglycaemia. Labetalol is often preferred.
- Lactation
- Compatible; monitor the infant for bradycardia.
Interactions
- Verapamil or diltiazemSevere bradycardia, AV block and heart failuremajor
- Amiodarone / digoxinAdditive bradycardia and AV blockmoderate
- Insulin and sulfonylureasMasking of hypoglycaemia warning symptomsmoderate
- Fluoxetine, paroxetine, bupropion (CYP2D6 inhibitors)Raised metoprolol levelsmoderate
- ClonidineRebound hypertension if clonidine is stopped abruptlymoderate
Adverse effects
Common
- Fatigue
- Bradycardia
- Cold extremities
- Dizziness
- Sleep disturbance
Serious
- Symptomatic bradycardia and heart block
- Decompensation if started during acute heart failure
- Bronchospasm at high doses
- Rebound ischaemia on abrupt withdrawal
Toxicity & overdose
Recognise and treat
- Overdose: bradycardia, hypotension, bronchospasm, seizures, hypoglycaemia
- Treat with atropine, IV fluids, glucagon, high-dose insulin-euglycaemia, and pacing or lipid emulsion in refractory cases
Alternatives
- Bisoprolol or carvedilol (both evidence-based in HFrEF)
- Nebivolol
- Diltiazem for rate control when beta-blockers are contraindicated and EF is preserved
Linked diseases & guidelines
ESC Guidelines for the management of acute coronary syndromes
Single unified ACS guideline covering STEMI and NSTE-ACS: reperfusion timing, antithrombotic strategy and secondary prevention.
European Society of CardiologyEurope2023
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Four-pillar therapy for HFrEF, SGLT2 inhibitors across the ejection-fraction spectrum, congestion management.
European Society of CardiologyEurope2023
Demo monograph for educational use. Always confirm dose, route and interactions against your national formulary and the product label before prescribing.
Demo content. Educational decision support only. Verify every dose, citation and recommendation against your national formulary and the primary source before clinical use.