Metoprolol succinate extended-release, in dosages of 100 to 400 mg once daily, produces similar β1-blockade as conventional metoprolol tablets administered two to four times daily. 5 mg IV over 1-2 minutes q5min; total dose not to exceed 15 mg2.5-5 mg IV q2-5min; not to exceed 15 mg over 10-15 minutes; maintenance: 25-100 mg PO q12hrSwitching from immediate-release to extended-release: Use same total daily dose of metoprololSwitching between oral and IV dosage forms: Equivalent beta-blocking effect is achieved in 2.5:1 (oral-to-IV) ratioIncreased triglyceride levels and insulin resistance, decreased high-density lipoprotein (HDL) levelsIschemic heart disease may be exacerbated after abrupt withdrawalHypersensitivity to catecholamines has been observed during withdrawalExacerbation of angina and, in some cases, myocardial infarction (MI) may occur after abrupt discontinuanceWhen long-term beta blocker therapy (particularly with ischemic heart disease) is discontinued, dosage should be gradually reduced over 1-2 weeks with careful monitoringIf angina worsens markedly or acute coronary insufficiency develops, beta-blocker administration should be promptly reinitiated, at least temporarily (in addition to other measures appropriate for unstable angina)Patients should be warned against interruption or discontinuance of beta-blocker therapy without physician adviceBecause coronary artery disease (CAD) is common and may be unrecognized, beta-blocker therapy must be discontinued slowly, even in patients treated only for hypertensionUse with caution in cerebrovascular insufficiency, CHF, cardiomegaly, myasthenia gravis, hyperthyroidism or thyrotoxicosis (may mask signs or symptoms), liver disease, renal impairment, peripheral vascular disease, psoriasis (may cause exacerbation of psoriasis)May exacerbate bronchospastic disease; monitor closelyBeta blockers can cause myocardial depression and may precipitate heart failure and cardiogenic shockSudden discontinuance can exacerbate angina and lead to MI and ventricular arrhythmias in patients with CADWorsening cardiac failure may occur during up-titration of metoprolol succinate; if such symptoms occur, increase diuretics and restore clinical stability before advancing the dose of metoprolol succinate; it may be necessary to lower the dose of metoprolol succinate or temporarily discontinue itBradycardia, including sinus pause, heart block, and cardiac arrest, has been reported; patients with 1° atrioventricular block, sinus node dysfunction, or conduction disorders may be at increased riskMay potentiate hypoglycemia in patients with diabetes mellitus and may mask signs and symptomsAvoid starting high-dose regimen of extended-release metoprolol in patients undergoing noncardiac surgery; use in patients with cardiovascular risk factors is associated with bradycardia, hypotension, stroke, and deathLong-term beta blockers should not be routinely withdrawn before major surgery; however, impaired ability of the heart to respond to reflex adrenergic stimuli may augment risks of general anesthesia and surgical proceduresMetoprolol loses beta-receptor selectivity at high doses and in poor metabolizersIf drug is administered for tachycardia secondary to pheochromocytoma, it should be given in combination with an alpha blocker (which should be started before metoprolol is started)While taking beta blockers, patients with history of severe anaphylactic reaction to variety of allergens may be more reactive to repeated challengeExtended release tablet should not be withdrawn routinely prior to major surgeryHydrochlorothiazide, can cause an idiosyncratic reaction, resulting in acute transient myopia and acute angle-closure glaucoma, which can lead to permanent vision loss if not treated; discontinue hydrochlorothiazide as rapidly as possible if symptoms occur; prompt medical or surgical treatments may need to be considered if intraocular pressure remains uncontrolled; risk factors for developing acute angle-closure glaucoma may include history of sulfonamide or penicillin allergyCaution in patients with history of psychiatric illness; may cause or exacerbate CNS depressionBeta-blockers can precipitate or aggravate symptoms of arterial insufficiency in patients with peripheral vascular diseaseThere are no adequate and well-controlled studies in pregnant womenLimited data on the use of metoprolol in pregnant womenRisk to fetus/mother is unknown; because animal reproduction studies are not always predictive of human response, use if clearly neededLopressor is excreted in breast milk in a very small quantityAn infant consuming 1 liter of breast milk daily would receive a dose of less than 1 mg of the drugA: Generally acceptable. 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