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1 High Alert TIME/ACTION PROFILE (cardiovascular effects)

ROUTE ONSET PEAK DURATION PDF Page #1
metoprolol (me-toe-proe-lole) PO† 15 min unknown 6–12 hr
Betaloc IV, Lopresor, Lopresor SR, Lopressor, Toprol-XL PO–ER unknown 6–12 hr 24 hr
Classification IV immediate 20 min 5–8 hr
Therapeutic: antianginals, antihypertensives †Maximal effects on BP (chronic therapy) may not occur for 1 wk. Hypotensive effects may per-
Pharmacologic: beta blockers sist for up to 4 wk after discontinuation

Pregnancy Category C Contraindications/Precautions

Indications
Hypertension. Angina pectoris. Prevention of MI and decreased mortality in patients
with recent MI. Management of stable, symptomatic (class II or III) heart failure due
to ischemic, hypertensive or cardiomyopathc origin (may be used with ACE inhibi-
tors, diuretics and/or digoxin; Toprol XL only). Unlabeled Use: Ventricular ar-
rhythmias/tachycardia. Migraine prophylaxis. Tremors. Aggressive behavior. Drug-
induced akathisia. Anxiety.
Action
Blocks stimulation of beta1(myocardial)-adrenergic receptors. Does not usually af-
fect beta2(pulmonary, vascular, uterine)-adrenergic receptor sites. Therapeutic
Effects: Decreased BP and heart rate. Decreased frequency of attacks of angina pec-
toris. Decreased rate of cardiovascular mortality and hospitalization in patients with
heart failure.
Pharmacokinetics
Absorption: Well absorbed after oral administration.
Distribution: Crosses the blood-brain barrier, crosses the placenta; small
amounts enter breast milk.
Metabolism and Excretion: Mostly metabolized by the liver (primarily by
CYP2D6; the CYP2D6 enzyme system exhibits genetic polymorphism); ⬃7% of
population may be poor metabolizers and may have significantlyqmetoprolol con-
centrations and anqrisk of adverse effects).
Half-life: 3– 7 hr.
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent.
Contraindicated in: Uncompensated HF; Pulmonary edema; Cardiogenic shock;
Bradycardia, heart block, or sick sinus syndrome (in absence of a pacemaker).
Use Cautiously in: Renal impairment; Hepatic impairment; Geri:qsensitivity to
beta blockers; initial dose reduction recommended; Pulmonary disease (including
asthma; beta1 selectivity may be lost at higher doses); Diabetes mellitus (may mask
signs of hypoglycemia); Thyrotoxicosis (may mask symptoms); Patients with a his-
tory of severe allergic reactions (intensity of reactions may be increased); Untreated
pheochromocytoma (initiate only after alpha blocker therapy started); OB, Lacta-
tion, Pedi: Safety not established; all agents cross the placenta and may cause fetal/
neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression.
Adverse Reactions/Side Effects
CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, mem-
ory loss, mental status changes, nervousness, nightmares. EENT: blurred vision,
stuffy nose. Resp: bronchospasm, wheezing. CV: BRADYCARDIA, HF, PULMONARY
EDEMA, hypotension, peripheral vasoconstriction. GI: constipation, diarrhea, drug-
induced hepatitis, dry mouth, flatulence, gastric pain, heartburn,qliver enzymes,
nausea, vomiting. GU: erectile dysfunction,plibido, urinary frequency. Derm:
rashes. Endo: hyperglycemia, hypoglycemia. MS: arthralgia, back pain, joint pain.
Misc: drug-induced lupus syndrome.
Interactions
Drug-Drug: General anesthesia, IV phenytoin, and verapamil may causeq
myocardial depression.qrisk of bradycardia when used with digoxin, verapamil,
diltiazem, or clonidine.qhypotension may occur with other antihypertensives,
acute ingestion of alcohol, or nitrates. Concurrent use with amphetamines, co-
caine, ephedrine, epinephrine, norepinephrine, phenylephrine, or pseu-
doephedrine may result in unopposed alpha-adrenergic stimulation (excessive hy-
Strikethrough ⫽ Discontinued.
Name /bks_53161_deglins_md_disk/metoprolol 02/17/2014 07:39AM
2 ● May causeqANA titers.
pertension, bradycardia). Concurrent administration of thyroid administration may
p effectiveness. May alter the effectiveness of insulins or oral hypoglycemic
agents (dose adjustments may be necessary). Maypthe effectiveness of theophyl-
line. Maypthe beneficial beta1-cardiovascular effects of dopamine or dobuta-
mine. Use cautiously within 14 days of MAO inhibitor therapy (may result in hyper-
tension).
Route/Dosage
When switching from immediate-release to extended-release
product, the same total daily dose can be used
PO (Adults): Antihypertensive/antianginal— 25– 100 mg/day as a single dose
initially or 2 divided doses; may beqq 7 days as needed up to 450 mg/day (immedi-
ate-release) or 400 mg/day (extended-release) (for angina, give in divided doses).
Extended-release products are given once daily. MI— 25– 50 mg (starting 15 min
after last IV dose) q 6 hr for 48 hr, then 100 mg twice daily. Heart failure— 12.5–
25 mg once daily (of extended-release), can be doubled every 2 wk up to 200 mg/
day. Migraine prevention— 50– 100 mg 2– 4 times daily (unlabeled).
IV (Adults): MI— 5 mg q 2 min for 3 doses, followed by oral dosing.
NURSING IMPLICATIONS
Assessment
● Monitor BP, ECG, and pulse frequently during dose adjustment and peri-
odically during therapy.
● Monitor frequency of prescription refills to determine compliance.
● Monitor vital signs and ECG every 5– 15 min during and for several
hours after parenteral administration. If heart rate ⬍40 bpm, especially
if cardiac output is also decreased, administer atropine 0.25– 0.5 mg IV.
● Monitor intake and output ratios and daily weights. Assess routinely for
signs and symptoms of HF (dyspnea, rales/crackles, weight gain, periph-
eral edema, jugular venous distention).
● Angina: Assess frequency and characteristics of anginal attacks periodically dur-
ing therapy.
● Lab Test Considerations: May causeqBUN, serum lipoprotein, potassium,
triglyceride, and uric acid levels.
Plate # 0-Composite pg 2 # 2
● May causeqin blood glucose levels.
● May causeqserum alkaline phosphatase, LDH, AST, and ALT levels. PDF Page #2
Potential Nursing Diagnoses
Decreased cardiac output (Side Effects)
Noncompliance (Patient/Family Teaching)
Implementation
● High Alert: IV vasoactive medications are inherently dangerous. Before adminis-
tering intravenously, have second practitioner independently check original order
and dose calculations.
● High Alert: Do not confuse Toprol-XL (metoprolol) with Topamax (topira-
mate). Do not confuse Lopressor with Lyrica. Do not confuse metoprolol tartrate
with metoprolol succinate.
● PO: Take apical pulse before administering. If ⬍50 bpm or if arrhythmia
occurs, withhold medication and notify health care professional.
● Administer metoprolol with meals or directly after eating.
● Extended-release tablets should be swallowed whole; do not break, crush, or
chew.
IV Administration
● Direct IV: Diluent: Administer undiluted. Concentration: 1 mg/mL. Rate:
Administer over 1 min.
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, alteplase, amikacin,
aminocaproic acid, aminophylline, amiodarone, amphotericin B liposome, ani-
dulafungin, argatroban, ascorbic acid, atropine, azathioprine, aztreonam, benz-
tropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, cal-
cium chloride, calcium gluconate, carboplatin, carmustine, caspofungin,
cefazolin, cefonocid, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftaroline,
ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cispla-
tin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine,
dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, dilti-
azem, diphenhydramine, dobutamine, docetaxel, dopamine, doxorubicin, doxy-
cycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide,
esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, flu-
conazole, fludarabine, fluorouracil, folic acid, furosemide, ganciclovir, gemcita-
bine, gentamicin, glycopyrrolate, granisetron, heparin, hetastarch, hydrocorti-
䉷 2015 F.A. Davis Company CONTINUED
Name /bks_53161_deglins_md_disk/metoprolol 02/17/2014 07:39AM Plate # 0-Composite pg 3 # 3

3 fore taking any Rx, OTC, or herbal products, especially cold preparations, concur-
CONTINUED
metoprolol
sone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin,
indomethacin, insulin, irinotecan, isoproterenol, ketorolac, labetalol, linezolid,
lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metho-
trexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, met-
ronidazole, midazolam, milrinone, mitoxantrone, morphine, multivitamins, my-
cophenolate, nafcillin, nalbuphine, naloxone, nitroprusside, norepinephrine,
octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron,
pamidronate, pancuronium, papaverine, pemetrexed, penicillin G, pentamidine,
pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phy-
tonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, pro-
cainamide, prochlorperazine, promethazine, propranolol, protamine, pyridox-
ime, quinupristin/dalfopristin, ranitidine, rocuronium, sodium bicarbonate,
streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline,
thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tol-
azoline, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vincris-
tine, vinorelbine, voriconazole, zoledronic acid.
● Y-Site Incompatibility: allopruinol, amphotericin B cholesteryl, amphotericin
B colloidal, amphotericin B lipid complex, dantrolene, diazepam, diazoxide, pan-
toprazole, phenytoin, trimethoprim/sulfamethoxazole.
Patient/Family Teaching
● Instruct patient to take medication as directed, at the same time each day, even if
feeling well; do not skip or double up on missed doses. Take missed doses as soon
as possible up to 8 hr before next dose. Abrupt withdrawal may precipitate
life-threatening arrhythmias, hypertension, or myocardial ischemia.
● Teach patient and family how to check pulse daily and BP biweekly and to report
significant changes to health care professional.
● May cause drowsiness. Caution patient to avoid driving or other activities that re-
quire alertness until response to the drug is known.
● Advise patient to change positions slowly to minimize orthostatic hypotension.
● Caution patient that this medication may increase sensitivity to cold.
● Instruct patient to notify health care professional of all Rx or OTC medications, vi-
tamins, or herbal products being taken and to consult health care professional be-
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent.
rently with this medication. Patients on antihypertensive therapy should also avoid
PDF Page #3
excessive amounts of coffee, tea, and cola.
● Diabetics should closely monitor blood glucose, especially if weakness, malaise,
irritability, or fatigue occurs. Medication does not block sweating as a sign of hy-
poglycemia.
● Advise patient to notify health care professional if slow pulse, difficulty
breathing, wheezing, cold hands and feet, dizziness, light-headedness,
confusion, depression, rash, fever, sore throat, unusual bleeding, or
bruising occurs.
● Instruct patient to inform health care professional of medication regimen before
treatment or surgery.
● Advise patient to carry identification describing disease process and medication
regimen at all times.
● Hypertension: Reinforce the need to continue additional therapies for hyperten-
sion (weight loss, sodium restriction, stress reduction, regular exercise, modera-
tion of alcohol consumption, and smoking cessation). Medication controls but
does not cure hypertension.
Evaluation/Desired Outcomes
● Decrease in BP.
● Reduction in frequency of anginal attacks.
● Increase in activity tolerance.
● Prevention of MI.
Why was this drug prescribed for your patient?
Strikethrough ⫽ Discontinued.