Section 02 · Monograph

Metoprolol

Reviewed Nov 2026FDA label

LopressorBeta-blocker

Indications

Hypertension — to lower blood pressure, reducing risk of fatal and non-fatal cardiovascular events (succinate ER and tartrate formulations)FDA-labeled
Angina pectoris — long-term management to reduce angina attacks and improve exercise toleranceFDA-labeled
Heart failure (NYHA II-IV, stable) — metoprolol succinate extended-release only, to reduce risk of cardiovascular mortality and heart-failure hospitalizationFDA-labeled
Acute myocardial infarction (metoprolol tartrate IV/oral, hemodynamically stable patients) — to reduce cardiovascular mortalityFDA-labeled

Migraine prophylaxis — NOT an FDA-approved indication for metoprolol (unlike propranolol and timolol, which do carry FDA-approved migraine prophylaxis indications); used off-label based on clinical evidence and guideline supportOff-label
Essential tremor (off-label)Off-label
Performance/situational anxiety (off-label)Off-label

Beta-1 selective (cardioselective) adrenergic receptor blocking agent at usual clinical doses
Reduces heart rate, myocardial contractility, and cardiac output, thereby decreasing myocardial oxygen demand
Suppresses renin release from the kidney, contributing to blood-pressure-lowering effect
At higher doses, selectivity for beta-1 receptors diminishes and beta-2 blockade can occur

Hypertension: initiate 25-100 mg/day (succinate ER) or 100 mg/day in divided doses (tartrate); titrate at weekly intervals; usual maintenance up to 400 mg/day
Angina: initiate 100 mg/day (succinate ER); titrate weekly; max 400 mg/day
Heart failure: initiate metoprolol succinate ER 12.5-25 mg once daily; double the dose approximately every 2 weeks as tolerated, target/max 200 mg/day
Off-label migraine prophylaxis (not FDA-labeled dosing): typical regimens in clinical practice range roughly 47.5-200 mg/day of the succinate ER formulation or 100-200 mg/day tartrate in divided doses — verify against current guideline-based dosing, as this is not derived from an FDA-approved indication
Discontinuation: taper gradually over 1-2 weeks; abrupt cessation can precipitate angina, MI, or ventricular arrhythmias

Renal/hepatic impairment: no specific dose adjustment required per label for renal impairment; use caution and consider lower doses in significant hepatic impairment

CYP2D6 inhibitors (e.g., fluoxetine, paroxetine, quinidine, propafenone) can substantially increase metoprolol concentrations
Catecholamine-depleting drugs (reserpine, MAO inhibitors) may produce additive hypotension and bradycardia
Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) and digitalis glycosides increase risk of bradycardia and AV conduction disturbances
Clonidine: concurrent use requires caution with discontinuation sequencing to avoid rebound hypertension
Other antihypertensives and negative inotropes/chronotropes have additive effects

Heart rate and blood pressure, especially during initiation and dose titration
Signs/symptoms of worsening heart failure (weight gain, edema, dyspnea) during up-titration
Blood glucose in diabetic patients (beta-blockade can mask tachycardia as a hypoglycemia warning sign)
Signs of bronchospasm in patients with reactive airway disease
ECG/PR interval if used with other AV-nodal blocking agents

Pregnancy: published observational data have not demonstrated a consistent drug-associated risk of major birth defects, though beta-blockers as a class have inconsistent reports of intrauterine growth restriction; use if potential benefit justifies potential fetal risk
Neonates of mothers treated with beta-blockers should be monitored for signs of bradycardia, hypotension, hypoglycemia, and respiratory depression
Lactation: metoprolol is present in human milk; estimated relative infant dose approximately 0.5-2% of the maternal weight-adjusted dosage; monitor breastfed infants for bradycardia and other beta-blocker effects