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Used alone or in combination with other antihypertensive agents for management of hypertension; long-term management of angina pectoris; MI (immediate-release tablets and injection); treatment of stable, symptomatic (New York Heart Association [NYHA] class II or III) heart failure of ischemic, hypertensive, or cardiomyopathic origin ( Toprol XL only).


Greater than first-degree heart block; significant first-degree heart block (PR interval of 0.24 sec or longer); CHF unless secondary to tachyarrhythmia treatable with beta-blockers; overt or moderate to severe cardiac failure; sick sinus syndrome (unless a permanent pacemaker is in place); sinus bradycardia; cardiogenic shock; hypersensitivity to beta-blockers; systolic BP below 100 mm Hg; heart rate less than 45 bpm; severe peripheral arterial circulatory disorders; second- and third-degree heart block; pheochromocytoma.

Adverse reactions:

Cardiovascular Bradycardia, edema, flushing, hypotension (3%); arterial insufficiency; CHF; palpitations; peripheral edema. CNS Dizziness, fatigue, headache, sleepiness (10%); depression (5%); drowsiness; forgetfulness; lethargy; paresthesias; vertigo. Dermatologic Pruritus, rash (5%); alopecia; facial erythema; urticaria. EENT Dry eyes; visual disturbances. GI Diarrhea, nausea, vomiting (5%); constipation; dry mouth; flatulence; gastric pain; heartburn. Genitourinary Difficulty with urination; impotence; urinary retention. Respiratory Shortness of breath (3%); bronchospasm; dyspnea; wheezing. Miscellaneous Asthenia; cold extremities; increased hypoglycemic response to insulin; may mask hypoglycemic signs; muscle cramps; systemic lupus erythematosus.


Barbiturates Bioavailability of metoprolol may decrease. Bupropion, diphenhydramine, fluoxetine, hydroxychloroquine, methimazole, paroxetine, propafenone, propylthiouracil, quinidine, ritonavir, terbinafine, thioridazine Effects of metoprolol may increase. Cimetidine May increase metoprolol levels. Clonidine May enhance or reverse antihypertensive effect; potentially life-threatening situations may occur, especially on abrupt withdrawal of clonidine. Digitalis glycosides Concomitant use may increase the risk of bradycardia. General anesthetics May enhance the cardiodepressant effect of beta-blockers. Hydralazine Serum levels of both drugs may increase. Lidocaine Lidocaine levels may increase, leading to toxicity. NSAIDs Some agents may impair antihypertensive effect. Prazosin Orthostatic hypotension may increase. Rifampin May decrease effects of metoprolol. Verapamil Effects of both drugs may be increased. Laboratory Test Interactions Antinuclear antibodies may develop but are usually reversible on discontinuation.


Ischemic heart disease In patients with angina pectoris or coronary artery disease (CAD), metoprolol may cause exacerbation of angina, occurrence of MI, and ventricular arrhythmias. Monitor patients closely because CAD is common and often unrecognized; it may be prudent not to discontinue beta-blocker therapy abruptly in patients being treated for hypertension. Bronchospastic disease In general, do not give beta-blockers to patients with bronchospastic disease. Major surgery The necessity of withdrawing beta-blocker therapy prior to surgery is controversial; the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures. Diabetes and hypoglycemia Use with caution in diabetic patients if a beta-blocker is required. Beta-blockers may mask tachycardia occurring with hypoglycemia, but other manifestations such as dizziness and sweating may not be significantly altered. Pheochromocytoma Use is contraindicated in patients with pheochromocytoma. Thyrotoxicosis Beta-blockers may mask certain clinical signs (eg, tachycardia) of hyperthyroidism. Carefully manage patients suspected of developing thyrotoxicosis to avoid abrupt withdrawal of beta blockade, which might precipitate a thyroid storm. Pregnancy Category C. Lactation Excreted in breast milk. Children Safety and efficacy not established (immediate-release); safety and efficacy not established in children younger than 6 yr of age (ER). Hypersensitivity While taking beta-blockers, patients with a history of severe anaphylactic reactions to a variety of allergens may be more reactive to repeated challenge, either accidental, diagnostic, or therapeutic. Hepatic Function Use with caution; reduced daily dose is advised. Anaphylaxis Deaths have occurred; aggressive therapy may be required. Atrioventricular block Slows AV conduction and may cause heart block. Bradycardia Metoprolol decreases heart rate in most patients. Cardiac failure Beta-blockers depress myocardial contractility and may precipitate or exacerbate cardiac failure. CHF Administer cautiously in CHF patients controlled by digitalis and diuretics. Hypokalemia Transient decreases in serum potassium levels may occur caused by intracellular shunting, which can produce adverse CV effects. Hypotension If systolic blood pressure decreases to 90 mm Hg or less, discontinue metoprolol. Peripheral vascular disease May precipitate or aggravate symptoms of atrial insufficiency.



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