Metoprolol succinate ER
TOPROL-XL
What it isMetoprolol succinate extended-release (TOPROL-XL, 1992) is a beta-1 antagonist for hypertension and heart failure.
Why this oneUnlike tartrate, succinate ER carries the heart-failure survival evidence from MERIT-HF; Tartrate:succinate is 1:1 total daily dose.
What limits itBradycardia and hypotension limit treatment. CYP2D6 inhibitors raise exposure; abrupt withdrawal can provoke ischemia.
FDA-approved for
- hypertension (1992)
- heart failure (~2000)
FDA label
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| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Hypertension | Adults | 25–100 mg QD | Titrate weekly to BP goal | >400 mg/day not studied |
| Hypertension | Pediatric ≥6 y | 1 mg/kg QD (max initial 50 mg) | Adjust to BP response | 2 mg/kg (≤200 mg) QD |
| Angina pectoris | Adults | 100 mg QD | Increase weekly to response | >400 mg/day not studied |
| Heart failure | Adults | NYHA II: 25 mg QD x2 wk; more severe: 12.5 mg QD | Double every 2 weeks as tolerated | 200 mg QD |
Titration Increase at weekly (or longer) intervals (hypertension/angina); heart failure: double dose every 2 weeks
Renal No adjustment needed
Hepatic Initiate at doses lower than recommended and increase gradually (metoprolol levels likely increased)
Instructions
- Administer once daily
- Tablets are scored and can be divided; do not crush or chew
- When switching from immediate-release metoprolol, use the same total daily dose
- Do not discontinue abruptly — taper over 1–2 weeks
- Heart failure: stabilize other HF therapy before initiation
Contraindications
- Severe bradycardia
- Second- or third-degree heart block
- Cardiogenic shock
- Decompensated heart failure
- Sick sinus syndrome (unless a permanent pacemaker is in place)
Cautions
- Do not stop abruptly (may exacerbate ischemia/precipitate MI)
- Worsening heart failure during up-titration
- Bronchospastic disease — use lowest possible dose
- Bradycardia/heart block
- Pheochromocytoma — initiate alpha-blocker first
- Avoid high-dose initiation before non-cardiac surgery
- May mask hypoglycemia
- Thyrotoxicosis — abrupt withdrawal may precipitate thyroid storm
- Peripheral vascular disease
- May be unresponsive to usual epinephrine doses for anaphylaxis
Adverse reactions
- Tiredness
- Dizziness
- Depression
- Shortness of breath
- Bradycardia
- Hypotension
- Diarrhea
- Pruritus
- Rash
Pregnancy Observational data show no clear increased birth-defect risk; inconsistent reports of IUGR/preterm birth; neonates may have hypotension, hypoglycemia, bradycardia, respiratory depression
Lactation Present in human milk in low amounts (0.5–2% of maternal weight-adjusted dose); monitor infant for bradycardia/hypoglycemia
NO BOXED WARNINGS
Principal riskBradycardia; abrupt withdrawal can precipitate ischemia
Classes and tags
Clinical profile
Mechanism of action: Metoprolol succinate ER ballicule
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