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Intravenous administration of calcium antagonists of the verapamil-type should not be given to patients treated with β-blockers.
Generally when treating patients with asthma, concomitant therapy with a β2-agonist (tablet and/or inhalation) should be administered. The dosage of β2-agonists may require adjustment (increase) when treatment with metoprolol is started.
During treatment with metoprolol, the risk of interfering with carbohydrate metabolism or masking hypoglycaemia is less than with non-selective β-blockers. Patients suffering from heart failure should have their decompensation treated both before and during treatment with metoprolol.
Very rarely, a pre-existing A-V conduction disorder of moderate degree may become aggravated (possibly leading to A-V block).
If the patients develop increasing bradycardia, metoprolol should be given in lower doses or gradually withdrawn.
Metoprolol may aggravate the symptoms of peripheral arterial circulatory disorders.
Where metoprolol is prescribed for a patient known to be suffering from a pheochromocytoma, an alpha-blocker should be given concomitantly.
Abrupt interruption of the medication is to be avoided. If treatment has to be withdrawn it should, when possible, be done gradually. Many patients can be withdrawn over a 14 day period.
This can be done by cutting the daily dose in sequential steps reaching a final dose of 25 mg once a day (half a 50 mg tablet).
During this period especially patients with known ischemic heart disease should be kept under close surveillance. The risk for coronary events, including sudden death, may increase during the withdrawal of β-blockade.
Prior to surgery the anaesthetist should be informed that the patient is receiving metoprolol. It is not recommended to stop β-blocker treatment in patients undergoing surgery. Acute initiation of high-dose metoprolol to patients undergoing non-cardiac surgery should be avoided, since it has been associated with bradycardia, hypotension and stroke including fatal outcome in patients with cardiovascular risk factors.
In patients taking β-blockers anaphylactic shock assumes a more severe form.
Effects on ability to drive and use machines: Patients should know how they react to metoprolol before they drive or use machines because occasionally dizziness or fatigue may occur.
