metoprolol

(me toe' proe lole)

Apo-Metoprolol (CAN), Betaloc (CAN), Lopresor (CAN), Lopressor,
Novometoprol (CAN), Nu-Metop (CAN), Toprol XL

Pregnancy Category C

Drug classes
Beta1-selective adrenergic blocker
Antihypertensive

Therapeutic actions
Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular
apparatus, decreasing the influence of the sympathetic nervous system on these tissues
and the excitability of the heart, decreasing cardiac output and the release of renin, and
lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone.

Indications
• Hypertension, alone or with other drugs, especially diuretics
• Immediate-release tablets and injection: Prevention of reinfarction in MI patients
who are hemodynamically stable or within 3–10 days of the acute MI
• Treatment of angina pectoris
• Toprol XL only: Treatment of stable, symptomatic CHF of ischemic, hypertensive,
or cardiomyopathic origin

Contraindications and cautions

• Contraindicated with sinus bradycardia (HR < 45 beats/min), second- or third-
degree heart block (PR interval > 0.24 sec), cardiogenic shock, CHF, systolic BP
< 100 mm Hg; lactation.
• Use cautiously with diabetes or thyrotoxicosis; asthma or COPD; pregnancy.

Available forms
Tablets—50, 100 mg; ER tablets—25, 50, 100, 200 mg; injection—1 mg/mL

Dosages
ADULTS
• Hypertension: Initially, 100 mg/day PO in single or divided doses; gradually
increase dosage at weekly intervals. Usual maintenance dose is 100–450 mg/day.
• Angina pectoris: Initially, 100 mg/day PO in 2 divided doses; may be increased
gradually, effective range 100–400 mg/day.
• MI, early treatment: Three IV bolus doses of 5 mg each at 2-min intervals with
careful monitoring. If these are tolerated, give 50 mg PO 15 min after the last IV
dose and q 6 hr for 48 hr. Thereafter, give a maintenance dosage of 100 mg PO
bid. Reduce initial PO doses to 25 mg, or discontinue in patients who do not
tolerate the IV doses.
 • MI, late treatment: 100 mg PO bid as soon as possible after infarct, continuing for
at least 3 mo and possibly for 1–3 yr.
Extended-release tablets
• Hypertension: 50–100 mg/day PO as 1 dose.
• Angina: 100 mg/day PO as 1 dose.
• CHF: 12.5–25 mg/day Toprol XL for 2 wk; may then be increased by 25 mg every
2 wk to a maximum of 200 mg.
PEDIATRIC PATIENTS
Safety and efficacy not established.

Pharmacokinetics
Route Onset Peak Duration
Oral 15 min 90 min 15–19 hr
IV Immediate 60–90 min 15–19 hr

Metabolism: Hepatic; T1/2: 3–4 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine

IV facts
Preparation: No additional preparation is required.
Infusion: Inject directly into vein or into tubing of running IV over 1 min. Inject as a
bolus; monitor carefully; wait 2 min between doses; do not give if bradycardia of < 45
beats/min, heart block, systolic pressure < 100 mm Hg.
Incompatibilities: Do not mix with amino acids, aztreonam, dopamine.

Adverse effects
• Allergic: Pharyngitis, erythematous rash, fever, sore throat, laryngospasm
• CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias,
sleep disturbances, hallucinations, disorientation, memory loss, slurred speech
• CV: CHF, cardiac arrhythmias, peripheral vascular insufficiency, claudication,
CVA, pulmonary edema, hypotension
• Dermatologic: Rash, pruritus, sweating, dry skin
• EENT: Eye irritation, dry eyes, conjunctivitis, blurred vision
• GI: Gastric pain, flatulence, constipation, diarrhea, nausea, vomiting, anorexia,
ischemic colitis, renal and mesenteric arterial thrombosis, retroperitoneal fibrosis,
hepatomegaly, acute pancreatitis
• GU: Impotence, decreased libido, Peyronie's disease, dysuria, nocturia, frequent
urination
• Musculoskeletal: Joint pain, arthralgia, muscle cramp
• Respiratory: Bronchospasm, dyspnea, cough, bronchial obstruction, nasal
stuffiness, rhinitis, pharyngitis
• Other: Decreased exercise tolerance, development of antinuclear antibodies
(ANA), hyperglycemia or hypoglycemia, elevated serum transaminase, alkaline
phosphatase
Interactions
Drug-drug
• Increased effects of metoprolol with verapamil, cimetidine, methimazole,
propylthiouracil
• Increased effects of both drugs if metoprolol is taken with hydralazine
• Increased serum levels and toxicity of IV lidocaine, if given concurrently
• Increased risk of orthostatic hypotension with prazosin
• Decreased antihypertensive effects if taken with NSAIDs, clonidine, rifampin
• Decreased therapeutic effects with barbiturates
• Hypertension followed by severe bradycardia if given concurrently with
epinephrine
Drug-lab test
• Possible false results with glucose or insulin tolerance tests (oral)

Nursing considerations
Assessment
• History: Sinus bradycardia (HR < 45 beats/min), second- or third-degree heart
block (PR interval > 0.24 sec), cardiogenic shock, CHF, systolic BP <
100 mm Hg; diabetes or thyrotoxicosis; asthma or COPD; lactation
• Physical: Weight, skin condition, neurologic status, P, BP, ECG, respiratory
status, kidney and thyroid function, blood and urine glucose

Interventions
• Do not discontinue drug abruptly after long-term therapy (hypersensitivity to
catecholamines may have developed, causing exacerbation of angina, MI, and
ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring.
• Ensure that patient swallows the ER tablets whole; do not cut, crush, or chew
them.
• Consult physician about withdrawing drug if patient is to undergo surgery
(controversial).
• Give oral drug with food to facilitate absorption.
• Provide continual cardiac monitoring for patients receiving IV metoprolol.

Teaching points
• Do not stop taking this drug unless instructed to do so by a health care provider.
• Swallow the ER tablets whole; do not cut, crush, or chew them.
• These side effects may occur: Dizziness, drowsiness, light-headedness, blurred
vision (avoid driving or dangerous activities); nausea, loss of appetite (eat
frequent small meals); nightmares, depression (discuss change of medication);
sexual impotence.
• Report difficulty breathing, night cough, swelling of extremities, slow pulse,
confusion, depression, rash, fever, sore throat.

Adverse effects in Italic are most common; those in Bold are life-threatening.