Metoprolol Succinate
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Indications, Uses, Dosage, Drugs Interactions, Side effects
Metoprolol Succinate
Medicine Type : Allopathy
Prescription Type:
Prescription Required
Approval : DCGI (Drugs Controller General of India)
Schedule
Schedule H
Pharmacological Class:
Beta-Blocker, Therapy Class:
Antihypertensive, Approved Countries
Sweden, Netherlands, New Zealand, US, India
Innovator name:
Bengt Ablad and Enar Carlsson
Metoprolol Succinate is an antihypertensive agent belonging to the beta-blocker class.
Metoprolol Succinate is approved for treating hypertension, angina, supraventricular tachycardia, ventricular tachycardia, congestive heart failure, and the prevention of migraine headaches. It is an adjunct in the treatment of hyperthyroidism.
Over 95% of an oral therapeutic dose of Metoprolol was typically recovered as the active pharmaceutical ingredient and metabolites in the urine. It is absorbed over a significant portion of the intestine. The action of CYP2D6 primarily regulates Metoprolol's metabolism and, to a lesser extent, the activity of CYP3A4. Less than 5% of an oral dose of metoprolol is recovered unchanged in the urine; the rest is excreted by the kidneys as metabolites that appear to have no beta-blocking activity.
The common side effects associated with Metoprolol include dizziness or lightheadedness, tiredness, depression, nausea, dry mouth, stomach pain, vomiting, constipation, rash or itching, runny nose, etc.
Metoprolol Succinate is available in the form of Tablets and Capsules.
The molecule is available in Sweden, the Netherlands, New Zealand, the US, India.
Metoprolol belongs to the antihypertensive class and acts as a cardio selective beta-1adrenergic receptor inhibitor class that competitively blocks beta1-receptors with minimal or no effects on beta-2 receptors at oral doses of less than 100 mg in adults. By reducing the heart's need for oxygen under any given level of exertion, metoprolol aids in the treatment of heart failure. Consequently, it is beneficial for the long-term treatment of angina pectoris.
Peak concentrations are attained after one dose of oral metoprolol succinate extendedrelease (ER) tablets in around 7 hours.
The peak plasma levels achieved after a similar dose of conventional metoprolol, taken once daily or in divided doses, are typically one-fourth to one-half lower after once-daily administration of metoprolol succinate extended-release tablet.
Metoprolol Succinate are available in various dosage form like- tablets and capsules.
Both oral tablets and extended-release (long-acting) tablets of metoprolol are available. As prescribed by the doctor, the regular tablet is often taken once or twice daily..
Metoprolol Succinate can be used:
To treat High Blood pressure
To Prevent Angina Pectoris
Migraine Headaches
Congestive Heart failure
Metoprolol Succinate is used alone or in combination with other medications to treat high blood pressure. By blocking catecholamine-induces increases in heart rate, in velocity and extend of myocardial contraction, and in blood pressure, Metoprolol is helpful in the
treatment of heart failure It works by affecting the response to nerve impulses in certain parts of the body, like the heart. As a result, the heart beats slower and decreases the blood pressure.
Metoprolol is approved for use in the following clinical indications:
High Blood Pressure: Beta-blocking medications' antihypertensive effects still lack a precise mechanism of action. However, several potential methods have been put forth: reduced cardiac output due to competing antagonistic interactions between catecholamines at peripheral (mainly cardiac) adrenergic neuron locations; decreased sympathetic outflow to the periphery due to a significant influence; and suppression of renin activity.
Angina Pectoris: Metoprolol is helpful in the long-term therapy of angina pectoris because it lowers the oxygen demands of the heart at any given amount of effort.
Migraine: Beta-blockers alleviate that pain by telling your blood vessels to relax so that the blood can flow normally.
Congestive heart failure: Metoprolol CR/XL is beneficial in treating individuals with ischemic or dilated cardiomyopathy who have stable mild to moderate (NYHA functional class II or III) chronic heart failure caused by left ventricular systolic dysfunction by reducing mortality and improving clinical status.
Metoprolol is available in tablet, capsule, and capsule forms. The method of administration of Metoprolol for various treatment are as follow:-
High Blood Pressure: 50 mg at night and 100 or 200 mg in the morning are the recommended starting doses for hypertension, depending on the patient's response. (The treating physician's clinical judgment should guide the dosage and length of the course of treatment.)
Angina pectoris: The initial dosage in hypertension is 50mg night and morning, increasing to 100 or 200mg per dose depending on the response. (The treating physician's clinical judgment should guide the dosage and length of the course of treatment.)
Migraine: The initial migraine dosage was 25-50mg/day, which was then increased to 50 mg per dose depending on the response. (The treating physician's clinical judgment should guide the dosage and length of the course of treatment.)
Congestive Heart failure: During up-titration, the dosage must be customized and continuously monitored. Diuretics, ACE inhibitors, and digitalis (if used) dosage should be stabilized before starting the metoprolol succinate extended-release pill. For patients with NYHA Class II heart failure, the starting dose of metoprolol succinate extended-release tablet is 25 mg once a day for two weeks, and patients with more severe heart failure, the starting dose is 12.5 mg once daily. The dose should subsequently be doubled every two weeks to the largest dosage the patient can bear, which is 200 mg of the extended-release pill metoprolol succinate. Increased diuretic dosages may be used to treat transitory worsening of heart failure, and it may also be essential to reduce the dose of metoprolol succinate extended-release.
Metoprolol is available in dosage strength of 25 mg, 50 mg, 100 mg, and 200 mg.
Metoprolol is available in various dosage form, i.e., Tablet and capsules
Metoprolol should be used in the treatment of high blood pressure, angina pectoris, migraine and congestive heart failure along with appropriate dietary restrictions
High Blood Pressure:
It has been observed that the low-salt Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure. Sometimes after a few weeks, its effects on blood pressure become noticeable.
Angina Pectoris:
Avoid foods that are high in saturated fat and hydrogenated or partially hydrogenated fats. Reduce your intake of dairy products including cheese, cream, and eggs.
Migraine:
Some common triggered diets include: Baked food with yeast, such as sourdough bread, bagels, doughnuts, coffee cake, Chocolate, Cultured dairy products (like yogurt and kefir), Tomatoes, Vegetables like onions, pea pods, some beans, corn, and sauerkraut, Vinegar and Alcohol must be avoided.
Congestive Heart Failure:
Avoid salt intake food as it can result in fluid retention. In those with heart failure, excess sodium can cause serious complications. It can also worsen high blood pressure, which can exacerbate existing heart failure.
Highly processed grains, like white bread, white rice, white pasta, and many sugarsweetened breakfast cereals, have been stripped of their fiber. That’s especially problematic for people with heart failure because it often co-exists with conditions like Type 2 diabetes and high cholesterol. Avoid any sort of processed and cured meats; they contain a lot of salt.
Even without seasoning, burgers and steaks pose a risk of clogged arteries due to their high fat content.
The contraindications of Metoprolol Succinate are indicated as:
Patient having High blood pressure and angina :
Metoprolol Succinate should not be taken if you have sinus bradycardia, a first-degree heart block, cardiogenic shock, or overt cardiac failure.
Patient with Hypersensitivity to other beta-blockers:
Metoprolol and similar derivatives, or any of the excipients (cross-sensitivity between beta-blockers can occur),sick-sinus syndrome, severe circulation problems can occur in the peripheral arteries.
For using Metoprolol following warnings and precautions must be taken.
The treating physician must closely monitor the patient and keep pharmacovigilance as follows:
Ischemic Heart Disease:
When treating patients with coronary artery disease with Metoprolol Succinate, do not stop the medication suddenly. Following the abrupt termination of beta-blocker therapy, individuals with coronary artery disease have experienced severe exacerbations of angina, myocardial infarction, and ventricular arrhythmias.
Bronchospastic Diseases:
Beta-Blockers should not be given to patients with bronchospastic diseases in general. However, metoprolol succinate extended-release tablet should be used cautiously in patients with bronchospastic illness who do not respond to, or cannot tolerate, alternative antihypertensive medication due to its relative beta1-selectivity. A beta2-stimulating medication should be taken concurrently because beta1- selectivity is not absolute. Additionally, the lowest dose of metoprolol succinate extended-release tablets should be used.
Diabetes and Hypoglycemia:
If a beta-blocker is needed, diabetic patients should utilise metoprolol succinate extended-release tablets with caution. While tachycardia brought on by hypoglycemia may be concealed by beta-blockers, other symptoms like perspiration and dizziness might not be severely impacted.
Thyrotoxicosis:
Beta-adrenergic blockade may conceal some clinical indications of hyperthyroidism, such as tachycardia. Care should be taken while managing patients who may be developing thyrotoxicosis to prevent sudden beta-blockade withdrawal, which could set off a thyroid storm.
Peripheral Vascular Disease:
Beta-blockers can precipitate or aggravate symptoms of arterial insufficiency in patients with peripheral vascular disease. Caution should be exercised in such individuals.
Precautions
Risk of Anaphylactic Reactions:
Patients who have previously experienced severe anaphylactic reactions to a range of allergens may be more sensitive to repeated challenges while using beta-blockers, whether they are accidental, diagnostic, or therapeutic. These people might not respond to the standard epinephrine dosages used to treat allergic reactions.
Until the patient's response to treatment with metoprolol Succinate has been determined, advise patients to refrain from operating vehicles, machinery, or engaging in other activities that call for attention; the patient should call their physician if they experience any breathing problems, and they should let their dentist or physician know before having any type of surgery that they are on metoprolol Succinate.
Alcohol Warning
Alcohol consumption while taking Metoprolol poses a health risk. Increased sleepiness, fainting, lightheadedness, and impaired vision may result from this combination. It might make unintentional injuries more likely.
Breast Feeding Warning
As a result of the low concentrations of Metoprolol in breastmilk, baby intake amounts are negligible and are not anticipated to have any negative effects on breastfed newborns. Studies on metoprolol use while nursing have not discovered any negative effects on breastfed infants. No particular safety measures are necessary.
Pregnancy Warning
Only use this medication if necessary in pregnancy. Use is recommended unless the benefit outweighs the risk; if pregnant, use only the smallest dose and stop using it at least two to three days before birth is anticipated, if possible.
Food Warning
The food warning while consuming Metoprolol that should be taken in concentrations while its consumptions:
Foods High in Potassium: Metoprolol, a beta-blocker, raises the blood potassium level. When beta-blockers are combined with potassium-rich meals including meat, milk, bananas, and sweet potatoes, elevated blood potassium levels can result.
Pleurisy Root: Cardiac glycosides in pleurisy root may obstruct Metoprolol's action.
Other Herbs: Metoprolol may interact with kava kava, valerian, ginseng, goldenseal, licorice, saw palmetto, hawthorn, ma huang, and Yohimbe. Those who use Metoprolol should refrain from consuming this herb.
The Adverse Reaction of Metoprolol for various treatment are as follow:
Common adverse effects:
Depression, slow heart rate, low blood pressure, dizziness etc. Other less severe expression are abnormal sexual function, itching, drowsiness, low energy, skin rashes, trouble breathing and diarrhea.
Infrequent adverse effect:
Chronic Heart Failure, Constriction of blood vessels of the extremities, worsening asthma, bronchospasm, constipation , difficulty in sleeping, nausea
Rare adverse effects:
Low Platelet count and bleeding from immune response and very low levels of granulocytes ( a type of white blood cells), blurred vision, etc
The clinically relevant drug interactions of Metoprolol is briefly summarized as:
Abatacept The metabolism of Metoprolol can be increased when combined with Abatacept.
Abiraterone The metabolism of Metoprolol can be decreased when combined with Abiraterone.
Acarbose The therapeutic efficacy of Acarbose can be increased when used in combination with Metoprolol.
Acebutolol Metoprolol may increase the arrhythmogenic activities of Acebutolol.
Aceclofenac Aceclofenac may decrease the antihypertensive activities of Metoprolol.
Acemetacin Acemetacin may decrease the antihypertensive activities of Metoprolol.
Acetaminophen The metabolism of Acetaminophen can be decreased when combined with Metoprolol.
Acetazolamide Acetazolamide may increase the excretion rate of Metoprolol which could result in a lower serum level and potentially a reduction in efficacy
Acetohexamide The therapeutic efficacy of Acetohexamide can be increased when used in combination with Metoprolol.
The common side effects of the Metoprolol succinate includes: Blurred vision, chest pain or discomfort, dizziness, faintness , slow or irregular heartbeat.
Several cases of overdosage have been reported, some leading to death.
Oral LD 50’s (mg/kg): mice, 1158-2460; rats, 3090-4670
The following signs and symptoms of metoprolol overdose are possible:
Bradycardia, Hypotension, Bronchospasm, Myocardial infarction, Cardiac failure, and Death.
There is no specific antidote. In general, patients with acute or recent myocardial infarction may be more hemodynamically unstable than other patients and should be treated. The following general steps should be taken in light of metoprolol SUCCINATE's pharmacologic effects:
Elimination of the Drug: Lavage of the stomach is necessary. Other clinical overdose signs should be treated symptomatically using current intensive care techniques.
Hypotension: It is necessary to deliver a vasopressor, such as levarterenol or dopamine.
Bronchospasm: A beta -stimulating agent and/or a theophylline derivative should be administered.
Cardiac Failure: It is necessary to administer a diuretic and a digitalis glycoside. Administration of dobutamine, isoproterenol, or glucagon may be considered in shock brought on by inadequate cardiac contractility.
Pharmacodynamics:
The following examples show relative beta1 selectivity:
Metoprolol Succinate is unable to counteract epinephrine's beta2-mediated vasodilating effects in healthy individuals. As opposed to the nonselective effect (beta1 plus beta2) beta-blockers, which completely reverse the vasodilating effects of epinephrine.
In asthmatic patients, Metoprolol Succinate reduces FEV1 and FVC significantly less than a nonselective beta-blocker, propranolol, at equivalent beta1-receptor blocking doses.
Metoprolol Succinate lacks intrinsic sympathomimetic activity, and membranestabilizing activity is detectable only at doses much greater than required for beta bloackade. Experiments on animals and people show that metoprolol succinate lowers AV nodal conduction and reduces the sinus rate.
Within an hour of oral treatment, there is a significant beta-blocking effect (measured by a decrease in exercise heart rate), and the duration is dose-related. In the case of single oral dosages of 20, 50, and 100 mg, the maximal impact was reduced by 50% at 3.3, 5.0, and 6.4 hours, respectively, in healthy volunteers.
Exercise-induced systolic blood pressure significantly decreased after several oral administrations of 100 mg twice daily at 12 hours. Maximum beta-blockade was reached after 20 minutes in normal participants when the medication was given over a 10-minute interval.In a ratio of around 2.5:1, oral and intravenous dosages have equivalent maxima
The drop in exercise heart rate and the log of plasma levels are correlated linearly. However, plasma levels do not seem to be correlated with antihypertensive action. Choosing the right dosage necessitates individual titration due to the varied plasma levels reached with a given dose and the lack of a consistent link between dose and antihypertensive action.
Stroke volume, diastolic blood pressure and pulmonary artery end-diastolic pressure remained unchanged.
Plasma concentration at one hour is linearly proportional to the oral dose between 50 and 400 mg in angina pectoris patients.. Exercise-induced heart rate and systolic blood pressure are decreased in proportion to the oral metoprolol dose logarithm. The relationship between the oral dose's logarithm and the improvement in exercise capacity and decrease in left ventricular ischemia is particularly noteworthy.
Pharmacokinetics:
A controlled-release medication called extended-release (ER) metoprolol succinate is created to administer metoprolol succinate at a nearly constant rate for about 20 hours regardless of meal intake or gastrointestinal pH. Even plasma concentrations over a 24-h period are produced by once-daily dosage of ER metoprolol succinate 12.5-200 mg, without the distinct peaks and troughs often seen with the immediate-release (IR) formulation.
Absorption:
Due to pre-systemic metabolism, which is saturable and causes a non-proportionate rise in exposure with higher dose, the estimated oral bioavailability of immediate-release Metoprolol is roughly 50%.
Distribution:
With a reported volume of distribution of 3.2 to 5.6 L/kg, Metoprolol is widely dispersed. Metoprolol is ten percent bound to serum albumin in plasma. Metoprolol has been identified in breast milk and is known to cross the placenta. Following oral administration, Metoprolol is also known to penetrate the blood-brain barrier, and CSF concentrations that are comparable to those seen in plasma have been documented. Metoprolol is not a significant P-glycoprotein.
Metabolism:
CYP2D6 is the enzyme that largely breaks down metoprolol Succinate. When taken orally, metoprolol, a racemic combination of R- and S- enantiomers, displays stereoselective metabolism that is reliant on oxidation phenotype. Only 2% of the majority of other populations and 8% of Caucasians are poor metabolizers of CYP2D6. Poor CYP2D6 metabolizers have plasma concentrations of metoprolol Succinate that are many times higher than those of extensive metabolizers with normal CYP2D6 activity, which reduces the cardioselectivity of metoprolol Succinate
Elimination:
Metoprolol Succinate is primarily eliminated through the liver's biotransformation process. Metoprolol has an average half-life of 3 to 4 hours for elimination; in people who have weak CYP2D6 metabolism, the half-life may be 7 to 9 hours. The majority of the dose —about 95%—can be retrieved in urine. Less than 5% of an oral dose and less than 10% of an intravenous dose are eliminated as unmodified pharmaceuticals in the urine in the majority of people (extensive metabolizers). Poor metabolizers may excrete up to 30% or 40% of oral or intravenous doses unaltered; the remaining portion is eliminated by the kidneys as metabolites that don't seem to have any beta-blocking effects. The stereoisomers renal clearance does not show stereo-selectivity in renal excretion.
There are some clinical studies mentioned below for drug metoprolol succinate:
Wikstrand J, Hjalmarson ÅK, et al. Study Group. Dose of metoprolol CR/XL and clinical outcomes in patients with heart failure: analysis of the experience in metoprolol CR/XL randomized intervention trial in chronic heart failure (MERITHF). Journal of the American College of Cardiology. 2002 Aug 7;40(3):491-8. DOI: https://doi.org/10.1016/S0735-1097(02)01970-8
Mittal N, Shafiq N, et al. Evaluation of efficacy of metoprolol in patients having heart failure with preserved ejection fraction: A randomized, double-blind, placebocontrolled pilot trial. Perspectives in Clinical Research. 2017 Jul;8(3):124. DOI : https://doi.org/10.4103/2229-3485.210449
Schellenberg R, Lichtenthal A, Wöhling H, et al. Nebivolol and Metoprolol for Treating Migraine: An Advance on β‐Blocker Treatment?. Headache: The Journal of Head and Face Pain. 2008 Jan;48(1):118-25. DOI: https://doi.org/10.1111/j.15264610.2007.00785.x
Fröhlich H, Torres L, et al. Bisoprolol compared with carvedilol and metoprolol succinate in the treatment of patients with chronic heart failure. Clinical Research in Cardiology. 2017 Sep;106(9):711-21. DOI : 10.1345/aph.1C286
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Parthika Patel
Parthika Patel has completed her Graduated B.Pharm from SSR COLLEGE OF PHARMACY and done M.Pharm in Pharmaceutics. She can be contacted at editorial@medicaldialogues.in. Contact no. 01143720751
Dr JUHI SINGLA
Dr JUHI SINGLA has completed her MBBS from Era’s Lucknow Medical college and done MD pharmacology from SGT UNIVERSITY Gurgaon. She can be contacted at editorial@medicaldialogues.in. Contact no. 011-43720751
