How fast to give metoprolol iv

It is given to people who have already had a heart attack. This medicine is a beta-blocker. 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. When the blood pressure is lowered, the amount of blood and oxygen is increased to the heart.

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make.

For this medicine, the following should be considered:. Tell your doctor if you have ever had any unusual or allergic reaction to this medicine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully. Appropriate studies have not been performed on the relationship of age to the effects of metoprolol injection in the pediatric population.

Safety and efficacy have not been established. Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of metoprolol injection in the elderly.

However, elderly patients may be more sensitive to the effects of metoprolol injection than younger adults and are more likely to have age-related liver or heart problems, which may require caution and an adjustment in the dose for patients receiving metoprolol injection.

Studies in women suggest that this medication poses minimal risk to the infant when used during breastfeeding. Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are receiving this medicine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below.

The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive. Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines. Encainide: Major Pharmacologically, beta-blockers, like metoprolol, cause AV nodal conduction depression and additive effects are possible when used in combination with encainide.

When used together, AV block can occur. Patients should be monitored closely and the dose should be adjusted according to clinical response. Enflurane: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Epoprostenol: Moderate Epoprostenol can have additive effects when administered with other antihypertensive agents, including beta-blockers. These effects can be used to therapeutic advantage, but dosage adjustments may be necessary.

Ergonovine: Major Whenever possible, concomitant use of beta-blockers and ergot alkaloids should be avoided, since propranolol has been reported to potentiate the vasoconstrictive action of ergotamine.

The risk of peripheral ischemia, resulting in cold extremities or gangrene, has been reported to be increased when ergot alkaloids are coadministered with selected beta-blockers, including propranolol, a beta-blocker commonly used for migraine prophylaxis.

Additionally, because of the potential to cause coronary vasospasm, ergot alkaloids could antagonize the therapeutic effects of anti-anginal agents including beta-blockers; clinicians should keep in mind that ergot alkaloids are contraindicated for use in patients with coronary heart disease or hypertension. Ergotamine: Moderate Concurrent use of beta-blockers and ergot alkaloids should be approached with caution.

Ergotamine; Caffeine: Moderate Concurrent use of beta-blockers and ergot alkaloids should be approached with caution. Ertugliflozin; Metformin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Escitalopram: Moderate Escitalopram is a modest inhibitor of CYP2D6, which can result in increased concentrations of drugs metabolized via the same pathway, including metoprolol. Coadministration of escitalopram and metoprolol had no clinically significant effects on blood pressure or heart rate; however, until further information becomes available, it may be advisable to monitor blood pressure and heart rate during coadministration of these drugs, particularly during treatment initiation and dose increases.

Estradiol Cypionate; Medroxyprogesterone: Minor Estrogens can induce fluid retention and may increase blood pressure in some patients; patients who are receiving antihypertensive agents concurrently with hormonal contraceptives should be monitored for antihypertensive effectiveness. Estradiol: Minor Estrogens can induce fluid retention and may increase blood pressure in some patients; patients who are receiving antihypertensive agents concurrently with hormonal contraceptives should be monitored for antihypertensive effectiveness.

Ethanol: Major Avoid alcoholic beverages ethanol when taking metoprolol extended-release capsules. Alcohol may cause a rapid release of metoprolol from the capsule, possibly resulting in increased side effects and reduced efficacy.

Etomidate: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Everolimus: Moderate Monitor for increased metoprolol adverse reactions, including bradycardia and hypotension, during coadministration with everolimus.

Exenatide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Fedratinib: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration of fedratinib. Felodipine: Moderate Coadministration of felodipine and metoprolol can reduce angina and improve exercise tolerance.

Fenoldopam: Major Avoid concomitant use of fenoldopam with beta-blockers due to the risk of hypotension. If used together, monitor blood pressure frequently. Beta-blockers may inhibit the sympathetic reflex response to fenoldopam. Fingolimod: Major If possible, do not start fingolimod in a patient who is taking a drug that slows the heart rate or atrioventricular conduction such as beta-blockers.

Use of these drugs during fingolimod initiation may be associated with severe bradycardia or heart block. Seek advice from the prescribing physician regarding the possibility to switch to drugs that do not slow the heart rate or atrioventricular conduction before initiating fingolimod. After the first fingolimod dose, overnight monitoring with continuous ECG in a medical facility is advised for patients who cannot stop taking drugs that slow the heart rate or atrioventricular conduction.

Experience with fingolimod in patients receiving concurrent therapy with drugs that slow the heart rate or atrioventricular conduction is limited. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents. Flecainide: Moderate Pharmacologically, beta-blockers, like metoprolol, cause AV nodal conduction depression and additive effects are possible when used in combination with flecainide.

During flecainide clinical trials, increased adverse events have not been reported in patients receiving combination therapy with beta-blockers and flecainide. However, patients should be monitored closely and the dose should be adjusted according to clinical response. Fluorescein: Moderate Patients on beta-blockers are at an increased risk of adverse reaction when administered fluorescein injection.

It is thought that beta-blockers may worsen anaphylaxis severity by exacerbating bronchospasm or by increasing the release of anaphylaxis mediators; alternately, beta-blocker therapy may make the patient more pharmacodynamically resistance to epinephrine rescue treatment.

Fluoxetine: Moderate Coadministration of metoprolol, a primary substrate of CYP2D6, and fluoxetine, a potent CYP2D6 inhibitor, may result in significantly increased metoprolol serum concentrations. Monitor for bradycardia, reduced blood pressure, and increased side effects of metoprolol if coadministered with fluoxetine.

One report noted an interaction between fluoxetine and metoprolol in which bradycardia occurred in a patient receiving metoprolol after fluoxetine was added. The patient had not previously experienced this reaction while on either drug alone.

The authors postulated that fluoxetine may have inhibited hepatic metabolism of metoprolol. Fluvoxamine: Moderate Fluvoxamine may potentiate the clinical effects of metoprolol, which is suspected to be due inhibition of metoprolol metabolism via CYP2D6. Food: Major Avoid administering marijuana and beta-blockers together as concurrent use may result in decreased beta-blocker efficacy.

Marijuana is known to produce significant increases in heart rate and cardiac output lasting for hours. Further, rare case reports of myocardial infarction and cardiac arrhythmias have been associated with marijuana use.

These marijuana-induced cardiovascular effects may be detrimental to patients requiring treatment with beta-blockers; thus, coadministration of beta-blockers and marijuana should be avoided. Fospropofol: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Galantamine: Moderate The increase in vagal tone induced by cholinesterase inhibitors, such as galantamine, may produce bradycardia or syncope. The vagotonic effect of galantamine may theoretically be increased when given with beta-blockers.

General anesthetics: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Ginger, Zingiber officinale: Minor In vitro studies have demonstrated the positive inotropic effects of certain gingerol constituents of ginger; but it is unclear if whole ginger root exhibits these effects clinically in humans. It is theoretically possible that excessive doses of ginger could affect the action of inotropes; however, no clinical data are available.

Glipizide; Metformin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Glucagon: Minor A temporary increase in both blood pressure and pulse rate may occur following the administration of glucagon.

Glyburide; Metformin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Guanabenz: Moderate Guanabenz can have additive effects when administered with other antihypertensive agents, including beta-blockers. Guanfacine: Moderate Guanfacine can have additive effects when administered with other antihypertensive agents, including beta-blockers. Haloperidol: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration.

Halothane: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension.

Icosapent ethyl: Moderate Beta-blockers may exacerbate hypertriglyceridemia and should be discontinued or changed to alternate therapy, if possible, prior to initiation of icosapent ethyl. Iloperidone: Moderate Secondary to alpha-blockade, iloperidone can produce vasodilation that may result in additive effects during concurrent use with antihypertensive agents.

If concurrent use of iloperidone and antihypertensive agents is necessary, patients should be counseled on measures to prevent orthostatic hypotension, such as sitting on the edge of the bed for several minutes prior to standing in the morning and rising slowly from a seated position.

Close monitoring of blood pressure is recommended until the full effects of the combination therapy are known. Iloprost: Moderate Additive reductions in blood pressure may occur when inhaled iloprost is administered to patients receiving other antihypertensive agents. Imatinib: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration. Incretin Mimetics: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Insulin Degludec; Liraglutide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Insulin Glargine; Lixisenatide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Insulins: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Intravenous Lipid Emulsions: Moderate High doses of fish oil supplements may produce a blood pressure lowering effect. Isocarboxazid: Moderate Additive hypotensive effects may be seen when monoamine oxidase inhibitors MAOIs are combined with antihypertensives.

Careful monitoring of blood pressure is suggested during concurrent therapy of MAOIs with beta-blockers. Limited data suggest that bradycardia is worsened when MAOIs are administered to patients receiving beta-blockers. Although the sinus bradycardia observed was not severe, until more data are available, clinicians should use MAOIs cautiously in patients receiving beta-blockers.

Patients should be instructed to rise slowly from a sitting position, and to report syncope or changes in blood pressure or heart rate to their health care provider. Isoflurane: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Isosorbide Mononitrate: Moderate Nitroglycerin can cause hypotension.

Isradipine: Moderate Although concomitant therapy with beta-blockers and isradipine is generally well tolerated and can even be beneficial in some cases, coadministration of these agents can induce excessive bradycardia or hypotension.

Isradipine when used in combination with beta-blockers, especially in heart failure patients, can result in additive negative inotropic effects. Finally, angina has been reported when beta-adrenergic blocking agents are withdrawn abruptly when isradipine therapy is initiated. A gradual downward titration of the beta-adrenergic blocking agent dosage during initiation of isradipine therapy can minimize or eliminate this potential interaction.

Patients should be monitored carefully, however, for excessive bradycardia, cardiac conduction abnormalities, or hypotension when these drugs are given together. In general, these reactions are more likely to occur with other non-dihydropyridine calcium channel blockers than with isradipine. Ivabradine: Moderate Monitor heart rate if ivabradine is coadministered with other negative chronotropes like beta-blockers.

Most patients receiving ivabradine will receive concomitant beta-blocker therapy. Coadministration of drugs that slow heart rate increases the risk for bradycardia. Ketamine: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension.

Lacosamide: Moderate Use lacosamide with caution in patients taking concomitant medications that affect cardiac conduction, such as beta-blockers, because of the risk of AV block, bradycardia, or ventricular tachyarrhythmia.

If use together is necessary, obtain an ECG prior to lacosamide initiation and after treatment has been titrated to steady-state.

In addition, monitor patients receiving lacosamide via the intravenous route closely. Lanreotide: Moderate Concomitant administration of bradycardia-inducing drugs e. Adjust the beta-blocker dose if necessary. Lasmiditan: Moderate Monitor heart rate if lasmiditan is coadministered with beta-blockers as concurrent use may increase the risk for bradycardia.

Lasmiditan has been associated with lowering of heart rate. In a drug interaction study, addition of a single mg dose of lasmiditan to a beta-blocker propranolol decreased heart rate by an additional 5 beats per minute. Levamlodipine: Moderate Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance.

Levobupivacaine: Moderate Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Levodopa: Moderate Concomitant use of beta-blockers with levodopa can result in additive hypotensive effects. Levothyroxine: Minor Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones.

The reduction of effects may be especially evident when a patient goes from a hypothyroid to a euthyroid state or when excessive amounts of thyroid hormone is given to the patient.

Levothyroxine; Liothyronine Porcine : Minor Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones. Levothyroxine; Liothyronine Synthetic : Minor Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones.

Lidocaine: Major Drugs such as beta-blockers that decrease cardiac output reduce hepatic blood flow and thereby decrease lidocaine hepatic clearance. Lidocaine; Prilocaine: Major Drugs such as beta-blockers that decrease cardiac output reduce hepatic blood flow and thereby decrease lidocaine hepatic clearance. Linagliptin; Metformin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Linezolid: Moderate Linezolid is an antibiotic that is also a reversible, non-selective MAO inhibitor. Bradycardia may be worsened when MAO-inhibitors are co-administered to patients receiving beta-blockers. Use linezolid cautiously in patients receiving beta-blockers. Liothyronine: Minor Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones.

Liraglutide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Lithium: Moderate Beta-blockers have been used to treat lithium-induced tremor.

Because tremor may be a sign of lithium toxicity and may be masked by the coadministration of beta-blockers, patients should be monitored for other clinical signs of lithium toxicity if these medications are taken concurrently. Other clinical signs of toxicity include: anorexia; visual impairment; drowsiness; muscular weakness; fasciculations or myoclonia; ataxia; dysarthria or slurred speech; stupor or coma; confusion or impaired cognition; seizures; and arrhythmias.

Limited data suggest that using propranolol, even in low doses, with lithium can lead to bradycardia and syncope. In addition, lithium renal clearance has been shown to be lower when propranolol was coadministered. It is not clear if these effects are unique for propranolol or hold true for all beta-blockers. Until more data are known, clinicians should use beta-blockers with caution in patients receiving lithium.

Lixisenatide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Lofexidine: Major Because both lofexidine and metoprolol can cause hypotension and bradycardia, concurrent use should be avoided if possible.

Patients being given lofexidine in an outpatient setting should be capable of and instructed on self-monitoring for hypotension, orthostasis, bradycardia, and associated symptoms. Lovastatin; Niacin: Moderate Cutaneous vasodilation induced by niacin may become problematic if high-dose niacin is used concomitantly with other antihypertensive agents.

This effect is of particular concern in the setting of acute myocardial infarction, unstable angina, or other acute hemodynamic compromise. Lurasidone: Moderate Due to the antagonism of lurasidone at alpha-1 adrenergic receptors, the drug may enhance the hypotensive effects of alpha-blockers and other antihypertensive agents.

If concurrent use of lurasidone and antihypertensive agents is necessary, patients should be counseled on measures to prevent orthostatic hypotension, such as sitting on the edge of the bed for several minutes prior to standing in the morning and rising slowly from a seated position. Magnesium Salicylate: Moderate Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow.

Mefloquine: Major Concurrent use of mefloquine and beta blockers can result in ECG abnormalities or cardiac arrest. Meglitinides: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Mephobarbital: Moderate Barbiturates can enhance the hepatic metabolism of beta-blockers that are significantly metabolized by the liver.

Beta-blockers that may be affected include metoprolol. Clinicians should monitor patients for loss of beta-blockade. Mepivacaine: Major Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Peripheral vasodilation may occur after use of mepivacaine.

Mepivacaine; Levonordefrin: Major Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Mestranol; Norethindrone: Minor Estrogen containing oral contraceptives can induce fluid retention and may increase blood pressure in some patients; monitor patients receiving concurrent therapy to confirm that the desired antihypertensive effect is being obtained. Metformin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Metformin; Repaglinide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Metformin; Rosiglitazone: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Metformin; Saxagliptin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Metformin; Sitagliptin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Methacholine: Moderate Beta-blockers may impair reversal of methacholine-induced bronchoconstriction with an inhaled rapid-acting beta-agonist.

Methohexital: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Methylergonovine: Moderate Concurrent use of beta-blockers and ergot alkaloids should be approached with caution.

Methysergide: Moderate Concurrent use of beta-blockers and ergot alkaloids should be approached with caution. Milrinone: Moderate Concurrent administration of antihypertensive agents could lead to additive hypotension when administered with milrinone. Titrate milrinone dosage according to hemodynamic response. Mirabegron: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration. Nefazodone: Minor Although relatively infrequent, nefazodone may cause orthostatic hypotension in some patients; this effect may be additive with antihypertensive agents.

Blood pressure monitoring and dosage adjustments of either drug may be necessary. Nesiritide, BNP: Major The potential for hypotension may be increased when coadministering nesiritide with antihypertensive agents. Neuromuscular blockers: Moderate Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. Niacin, Niacinamide: Moderate Cutaneous vasodilation induced by niacin may become problematic if high-dose niacin is used concomitantly with other antihypertensive agents.

Niacin; Simvastatin: Moderate Cutaneous vasodilation induced by niacin may become problematic if high-dose niacin is used concomitantly with other antihypertensive agents. Nifedipine: Moderate In general, concomitant therapy of nifedipine with beta-blockers is well tolerated and can even be beneficial in some cases i. Finally, angina has been reported when beta-adrenergic blocking agents are withdrawn abruptly and nifedipine therapy is initiated. A gradual downward titration of the beta-adrenergic blocking agent dosage during initiation of nifedipine therapy may minimize or eliminate this potential interaction.

Hypotension and impaired cardiac performance can occur during coadministration of nifedipine with beta-blockers, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. Monitor clinical response during coadministration; adjustment of nifedipine dosage may be needed during concurrent beta-blocker therapy.

Nimodipine: Moderate Nimodipine, a selective calcium-channel blocker, can enhance the antihypertensive effects of beta-blockers. Nisoldipine: Moderate Concurrent use of nisoldipine with metoprolol can be beneficial i. Nitrates: Moderate Nitroglycerin can cause hypotension. Nitroglycerin: Moderate Nitroglycerin can cause hypotension. Nitroprusside: Moderate Additive hypotensive effects may occur when nitroprusside is used concomitantly with other antihypertensive agents. Dosages should be adjusted carefully, according to blood pressure.

Non-Ionic Contrast Media: Moderate Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. Nonsteroidal antiinflammatory drugs: Moderate If nonsteroidal anti-inflammatory drugs NSAIDs and an antihypertensive drug are concurrently used, carefully monitor the patient for signs and symptoms of renal insufficiency and blood pressure control.

Doses of antihypertensive medications may require adjustment in patients receiving concurrent NSAIDs. NSAIDs, to varying degrees, have been associated with an elevation in blood pressure. This effect is most significant in patients receiving concurrent antihypertensive agents and long-term NSAID therapy. NSAIDs cause a dose-dependent reduction in prostaglandin formation, which may result in a reduction in renal blood flow leading to renal insufficiency and an increase in blood pressure that are often accompanied by peripheral edema and weight gain.

Patients who rely upon renal prostaglandins to maintain renal perfusion may have acute renal blood flow reduction with NSAID usage. Elderly patients may be at increased risk of adverse effects from combined long-term NSAID therapy and antihypertensive agents, especially diuretics, due to age-related decreases in renal function and an increased risk of stroke and coronary artery disease.

Olanzapine: Moderate Olanzapine may induce orthostatic hypotension and thus enhance the effects of antihypertensive agents. Olanzapine; Fluoxetine: Moderate Coadministration of metoprolol, a primary substrate of CYP2D6, and fluoxetine, a potent CYP2D6 inhibitor, may result in significantly increased metoprolol serum concentrations. Moderate Olanzapine may induce orthostatic hypotension and thus enhance the effects of antihypertensive agents. Olanzapine; Samidorphan: Moderate Olanzapine may induce orthostatic hypotension and thus enhance the effects of antihypertensive agents.

Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: Moderate Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance.

Plasma concentrations and efficacy of metoprolol may be reduced if these drugs are administered concurrently. Oxymetazoline: Major The vasoconstricting actions of oxymetazoline, an alpha adrenergic agonist, may reduce the antihypertensive effects produced by beta-blockers.

If these drugs are used together, closely monitor for changes in blood pressure. Ozanimod: Moderate Ozanimod may cause bradycardia and AV-conduction delays, which may be enhanced with the concomitant use of beta-blockers.

Paliperidone: Moderate Paliperidone may cause orthostatic hypotension, thereby enhancing the hypotensive effects of antihypertensive agents. Orthostatic vital signs should be monitored in patients receiving paliperidone and beta-adrenergic blockers who are susceptible to hypotension.

Panobinostat: Major The co-administration of panobinostat and metoprolol is not recommended. If concomitant use cannot be avoided, closely monitor patients for signs and symptoms of metoprolol toxicity. Paroxetine: Moderate Paroxetine impairs metabolism of the hepatic CYP2D6 isoenzyme pathway at therapeutic doses, resulting in substantial increases in concentrations of other drugs metabolized via the same pathway, including metoprolol.

Clinicians should use paroxetine cautiously with metoprolol; downward dose adjustments of the beta-blocker may be required if paroxetine is initiated; alternatively an upward dose adjustment of the beta blocker may be needed if paroxetine is discontinued.

Patients should be advised to report increased effects of these medications, including hypotension or increased dizziness to their health care professional. Pasireotide: Major Pasireotide may cause a decrease in heart rate.

Closely monitor patients who are also taking drugs associated with bradycardia such as beta-blockers. Dose adjustments of beta-blockers may be necessary. Pentoxifylline: Moderate Pentoxifylline has been used concurrently with antihypertensive drugs beta blockers, diuretics without observed problems. Small decreases in blood pressure have been observed in some patients treated with pentoxifylline; periodic systemic blood pressure monitoring is recommended for patients receiving concomitant antihypertensives.

If indicated, dosage of the antihypertensive agents should be reduced. Perindopril; Amlodipine: Moderate Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. Phenelzine: Moderate Additive hypotensive effects may be seen when monoamine oxidase inhibitors MAOIs are combined with antihypertensives.

Phenothiazines: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration. Phenoxybenzamine: Moderate Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. Phentolamine: Moderate Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers.

Pilocarpine: Moderate Systemically administered pilocarpine e. The risk of conduction disturbances with beta-blockers and ophthalmically administered pilocarpine is low. Pioglitazone; Metformin: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Ponesimod: Moderate Monitor for decreases in heart rate if concomitant use of ponesimod and beta-blockers is necessary. Consider a temporary interruption in beta-blocker therapy before initiating ponesimod in patients with a resting heart rate less than or equal to 55 bpm. Beta-blocker treatment can be initiated in patients receiving stable doses of ponesimod. Concomitant use of another beta-blocker with ponesimod resulted in a mean decrease in heart rate of Pramlintide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Prazosin: Moderate Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. Prilocaine: Moderate Local anesthetics may cause additive hypotension in combination with antihypertensive agents.

Prilocaine; Epinephrine: Moderate Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Primidone: Moderate Barbiturates can enhance the hepatic metabolism of beta blockers that are significantly metabolized by the liver, such as metoprolol. Clinicians should monitor patients for loss of beta blockade. Procainamide: Major High or toxic concentrations of procainamide may prolong AV nodal conduction time or induce AV block; these effects could be additive with the pharmacologic actions of beta-blockers, like metoprolol.

Procainamide's elimination half-life was not significantly changed when administered concomitantly with metoprolol. Procaine: Minor Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Propafenone: Major Pharmacologically, beta-blockers, like metoprolol, cause AV nodal conduction depression and additive effects are possible when used in combination with propafenone. Propafenone a CYP2D6 inhibitor, has been shown to increase the plasma concentrations and prolong the elimination half-life of metoprolol, with potential for adverse effects.

Dosages of metoprolol may need to be reduced when used concomitantly with propafenone. Propofol: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Quinine: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration.

Ranolazine: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration. Rasagiline: Moderate Additive hypotensive effects may be seen when monoamine oxidase inhibitors MAOIs are combined with antihypertensives. Reserpine: Moderate Reserpine may have additive orthostatic hypotensive effects when used with beta-blockers due to catecholamine depletion.

Beta-blockers may also interfere with reflex tachycardia, worsening the orthostasis. Patients treated concurrently with a beta-blocker and reserpine should be monitored closely for evidence of hypotension or marked bradycardia and associated symptoms e. Risperidone: Moderate Risperidone may induce orthostatic hypotension and thus enhance the hypotensive effects of metoprolol. Lower initial doses or slower dose titration of risperidone may be necessary in patients receiving metoprolol concomitantly.

Rivastigmine: Moderate The increase in vagal tone induced by some cholinesterase inhibitors may produce bradycardia, hypotension, or syncope. The vagotonic effect of these drugs may theoretically be increased when given with other medications known to cause bradycardia such as beta-blockers. Rolapitant: Moderate Monitor for increased metoprolol adverse reactions including bradycardia and hypotension during coadministration. Metoprolol is a CYP2D6 substrate and rolapitant is a moderate CYP2D6 inhibitor; the inhibitory effect of rolapitant is expected to persist beyond 28 days for an unknown duration.

Ropivacaine: Moderate Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Salsalate: Moderate Concurrent use of beta-blockers with salsalate and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. Semaglutide: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Sevoflurane: Major General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. SGLT2 Inhibitors: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Silodosin: Moderate During clinical trials with silodosin, the incidence of dizziness and orthostatic hypotension was higher in patients receiving concomitant antihypertensive treatment.

Thus, caution is advisable when silodosin is administered with antihypertensive agents. In addition, increased concentrations of silodosin may occur if it is coadministered with carvedilol; exercise caution. Carvedilol is a P-glycoprotein P-gp inhibitor and silodosin is a P-gp substrate. Siponimod: Moderate Monitor for significant bradycardia with coadministration of siponimod and beta-blockers, as additive lowering effects on heart rate may occur; temporary interruption of beta-blocker treatment may be necessary prior to siponimod initiation.

Beta-blocker treatment can be initiated in patients receiving stable doses of siponimod. Sufentanil: Moderate The incidence and degree of bradycardia and hypotension during induction with sufentanil may be increased in patients receiving beta-blockers. Sulfonylureas: Moderate Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents.

Sympathomimetics: Minor Close monitoring of blood pressure or the selection of alternative therapeutic agents to the sympathomimetic agent may be needed in patients receiving a beta-blocker.

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