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Metoprolol (Oral Route) Side Effects

Side Effects

Drug information provided by: IBM Micromedex

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

More common

  1. Blurred vision

  2. chest pain or discomfort

  3. confusion

  4. dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position

  5. slow or irregular heartbeat

  6. sweating

  7. unusual tiredness or weakness
Less common

  1. Bloating or swelling of the face, arms, hands, lower legs, or feet

  2. cough

  3. decreased urine output

  4. difficult or labored breathing

  5. difficulty with speaking

  6. dilated neck veins

  7. disturbed color perception

  8. double vision

  9. extreme tiredness or weakness

  10. fast, pounding, or racing heartbeat or pulse

  11. halos around lights

  12. headache

  13. inability to move the arms, legs, or facial muscles

  14. inability to speak

  15. irregular breathing

  16. loss of vision

  17. night blindness

  18. noisy breathing

  19. overbright appearance of lights

  20. pain, tension, and weakness upon walking that subsides during periods of rest

  21. paleness or cold feeling in the fingertips and toes

  22. rapid weight gain

  23. seeing, hearing, or feeling things that are not there

  24. short-term memory loss

  25. slow speech

  26. swelling of the face, fingers, feet, or lower legs

  27. tightness in the chest

  28. tingling of the hands or feet

  29. tingling or pain in the fingers or toes when exposed to cold temperatures

  30. troubled breathing

  31. tunnel vision

  32. unusual weight gain or loss
Rare

  1. Bluish color of the skin of the fingers or toes

  2. chills

  3. clay-colored stools

  4. continuing loss of appetite

  5. continuing or severe abdominal or stomach pain

  6. continuing or severe nausea and vomiting

  7. dark urine

  8. difficulty with moving

  9. fever

  10. general tiredness and weakness

  11. hoarseness

  12. increased frequency of urination

  13. itching skin

  14. light-colored stools

  15. lower back or side pain

  16. muscle pain or stiffness

  17. numbness of the fingers or toes

  18. pain, swelling, or redness in the joints

  19. rash

  20. sore throat

  21. sores, ulcers, or white spots on the lips or in the mouth

  22. unpleasant breath odor

  23. unusual bleeding or bruising

  24. upper right abdominal or stomach pain

  25. vomiting of blood

  26. weakness

  27. yellow eyes and skin
Incidence not known

  1. Black, tarry stools

  2. bleeding gums

  3. blood in the urine or stools

  4. burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings

  5. cool, sweaty skin

  6. pinpoint red spots on the skin

Get emergency help immediately if any of the following symptoms of overdose occur:

Symptoms of overdose

  1. Bluish color of the fingernails, lips, skin, palms, or nail beds

  2. change in consciousness

  3. loss of consciousness

  4. no blood pressure or pulse

  5. stopping of the heart

  6. very drowsy or sleepy

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

Less common

  1. Belching

  2. bloated feeling

  3. decreased interest in sexual intercourse

  4. difficulty having a bowel movement

  5. discouragement

  6. dry mouth

  7. excess air or gas in stomach or bowels

  8. feeling of constant movement of self or surroundings

  9. feeling of fullness

  10. feeling of indigestion

  11. feeling sad or empty

  12. inability to have or keep an erection

  13. irritability

  14. loss in sexual ability, desire, drive, or performance

  15. loss of interest or pleasure

  16. nightmares

  17. pain in the chest below the breastbone

  18. passing gas

  19. redness or other discoloration of the skin

  20. runny nose

  21. sensation of spinning

  22. sneezing

  23. stuffy nose

  24. tiredness

  25. trouble concentrating

  26. trouble sleeping
Rare

  1. Bone pain

  2. continuing ringing or buzzing or other unexplained noise in the ears

  3. dry eyes

  4. hair loss or thinning of the hair

  5. hearing loss

  6. increased sensitivity of the skin to sunlight

  7. pain in the penis on erection

  8. severe sunburn
Incidence not known

  1. Change in taste or bad, unusual, or unpleasant (after) taste

  2. fear or nervousness

  3. hives or welts

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

 

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Portions of this document last updated: Sept. 01, 2021

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.

A Review of Current Literature

Abstract

Antiarrhythmic drugs are commonly prescribed cardiac drugs. Due to their receptor mimicry with several of the gastrointestinal tract receptors, they can frequently lead to gastrointestinal side effects. These side effects are the most common reasons for discontinuation of these drugs by the patients. Knowledge of these side effects is important for clinicians that manage antiarrhythmic drugs. This review focuses on the gastrointestinal side effects of these drugs and provides a detailed up-to-date literature review of the side effects of these drugs. The review provides case reports reported in the literature as well as possible mechanisms that lead to gastrointestinal side effects.

Keywords: antiarrhythmic drugs, cardiac drugs, cardiac pharmacology, gastrointestinal side effects, drug side effects

Introduction and background

Antiarrhythmics are commonly prescribed drugs and have a narrow therapeutic window. These medications mainly affect the ion channel in the cardiac cell membrane. They are pro-arrhythmogenic and can also cause systemic side effects including gastrointestinal side effects. Antiarrhythmic drugs have sometimes been discontinued because of these side effects. For example, amiodarone is known for pro-arrhythmogenic side effects but there are instances where the drug is stopped because of liver toxicity. Based on the Vaughan Williams classification of antiarrhythmic drugs, they are classified into four classes depending on the mechanism of action (Table ) [1]. Class 1 is further classified into a, b, and c. Antiarrhythmics are prescribed based on an individualized approach, not following the Vaughan classification. They are either used as a single drug or in combination with multiple drugs. Some of the antiarrhythmics have more than one class action; for example, amiodarone has all four class effects and sotalol has class 2 and 3 effects. As most antiarrhythmics are metabolized and eliminated by the liver, chronic use or overdose of these drugs can lead to hepatotoxicity.

Table 1

Classification of Antiarrhythmic Medications

Modified from Kowey, et al. [1]

Classes Membrane Effect Drugs
Class 1a Sodium channel block; intermediate kinetics, and potassium channel block Quinidine, procainamide hydrochloride, disopyramide
Class 1b Sodium channel block; rapid kinetics Lidocaine, tocainide, mexiletine hydrochloride, phenytoin
Class 1c Sodium channel block with slow kinetics Flecainide and propafenone
Class 2 Beta-receptor blocker Propranolol, metoprolol, esmolol, acebutolol, atenolol
Class 3 Potassium channel blocker, slow sodium channel facilitation Procainamide, sotalol, dronedarone, dofetilide
Class 4 Calcium channel blocker Verapamil and diltiazem
Digitalis Sodium potassium ATPase inhibition Digoxin, digitoxin
Adenosine
 
Inhibit cyclic adenosine monophosphate (cAMP) mediated calcium influx Adenosine

Review

Class 1a

Class 1a drugs include quinidine, disopyramide, and procainamide.

Quinidine

Quinidine is an optical isomer of quinine and is derived from the bark of cinchona. Quinine is used for the treatment of parasitic infections, such as malaria. Quinidine is an older drug and not used frequently because of the development of newer antiarrhythmic drugs.

Studies have shown that quinidine causes hepatotoxicity in 2% to 2.2% population. Cases presented in the literature are mostly of granulomatous hepatitis (Table ) [2]. Clinical presentation of hepatitis, such as fever, rash, thrombocytopenia, reversibility on discontinuation of the drug, and reappearance after rechallenge, explains quinidine hepatitis as a hypersensitivity reaction. When hepatotoxicity develops, treatment is discontinuation of the medication.

Table 2

Comparison of Cases of Disopyramide-induced Hepatotoxicity

References Age (Years)/ Sex Symptom, signs and labs Duration of drug use Outcome
  Repeat Exposure
Scheinman, et al. [8] 62/Male Anxiety, dyspnea, abdomen pain, elevated aspartate aminotransferase, and lactate dehydrogenase One day Hepatic necrosis with congestion on biopsy, disopyramide was discontinued and liver enzymes and symptoms improved on day six. Disopyramide was restarted but the patient again had a recurrence of anxiety and dyspnea, it was discontinued. Liver enzymes did not elevate. Antiarrhythmic was changed to procainamide.
Scheinman, et al. [8] 61/Male Hypotension, chest pain, 1+ edema lower extremity, bilateral lung bases rales, hepatomegaly. 
Aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase were elevated
One day Symptoms improved with diuresis and liver enzymes normalized. Nausea, dyspnea, and hypotension developed one day after readministration of disopyramide. Liver enzymes peaked; the drug was switched to procainamide and liver enzymes normalized in few days.
Doody [10] 55/Female Elevated liver enzymes and disseminated intravascular coagulation (prolonged prothrombin time, elevated fibrin split products) Unknown Both liver enzymes and liver functions improved 14 days after discontinuation of therapy. No
Barkins, et al. [9] Unknown Jaundice and abnormal liver enzymes One week Prompt clinical resolution on discontinuation of the drug. No

As a result of its prolonged transit time, quinidine has also been reported to cause esophagitis. On average, most cases are seen at the age of 60; esophagitis caused by quinidine can lead to strictures. The condition can be prevented by taking pills in sitting position and with plenty of water. Acid suppression with histamine h3 blockers, sucralfate, and proton pump inhibitors are commonly used but their efficacy has not been clearly established. In cases where complications like strictures and perforation develop, surgical intervention may be needed [6]. Quinidine rarely causes pill-induced gastritis; however, one case of gastric ulceration has been reported. The case was managed with discontinuation of drug and use of sucralfate and rabeprazole [7].

Disopyramide

Disopyramide has similar electrophysiological properties as quinidine with fewer gastrointestinal side effects. It is mainly used for the treatment of ventricular tachycardia.

Due to anticholinergic action, disopyramide can cause constipation and dry mouth, which can be controlled by the acetylcholinesterase inhibitor, pyridostigmine. Studies show that pyridostigmine has no significant effect on antiarrhythmic properties of the drug. Although disopyramide has fewer gastrointestinal side effects, cases of hepatotoxicity have been reported, as well as hepatic ischemia secondary to cardiac failure by passive congestion. The drug has a negative ionotropic effect which can worsen heart failure. Liver functions and symptoms improved after the discontinuation of the drug, and in one case, diuretics were used to resolve congestion [8]. Rarely, disopyramide can cause cholestatic jaundice that, in most cases, appears within the first week of taking the medication. Generally, cholestatic jaundice resolves promptly on discontinuation of the drug (Table ) [9]. A case of severe hepatocellular toxicity with disseminated intravascular coagulation was reported, which improved after discontinuation of disopyramide [10].

Table 3

Summary and Comparison of a Few Cases of Quinidine-induced Hepatotoxicity

References Age (Years)/ Sex Symptoms, signs and labs Duration of Drug Use Outcome
  Repeat Exposure
Guharoy, et al. [3] 62/Male Diarrhea, nausea, fever, palpitations, elevated aspartate aminotransferase, and alanine aminotransferase Two weeks Symptoms resolved in 42 hours, liver enzymes started decreasing gradually and normalized on day 12. No
Bramlet, et al. [2] Unknown Fever, urticaria, and mild thrombocytopenia Unknown Histology showed granulomatous hepatitis. Symptoms resolved with discontinuation of the drug. Symptoms appeared three days after readministration
Handler, et al. [4] 72/Female Anorexia, weight loss, elevated aspartate aminotransferase, alkaline phosphatase, and lactate dehydrogenase 16 months Active hepatitis on liver biopsy, liver functions normalized after discontinuation of the drug. Re-challenge with the drug caused elevation of liver enzymes and lactate dehydrogenase
Hogan, et al. [5] 85/Male Jaundice and vomiting, elevated aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase, and total bilirubin 8 days Biopsy showed centrilobular cholestasis and granulomatous hepatitis. Quinidine stopped on day 10 and liver functions started improving. No

Procainamide

Procainamide is frequently used for atrial and ventricular arrhythmias. Although rare, procainamide can cause hepatotoxicity and cases have been reported of granulomatous and intrahepatic cholestasis. Hepatotoxicity caused by procainamide is due to an unknown mechanism, but most likely it is secondary to hypersensitivity. Clinical features of hypersensitivity, including fever, rash, and nausea, are usually present. In most cases, liver function improves in days to weeks on discontinuation of the drug. There is only one case reported of acute pancreatitis secondary to procainamide drug-induced lupus [11]. Due to anticholinergic action, procainamide can cause constipation. The literature has only one report of a case of pseudo-obstruction in a diabetic patient with procainamide, which can happen with both oral and intravenous forms of the drug. The condition improved with the discontinuation of the drug [12].

Class 1b

Class 1b drugs include lidocaine, phenytoin, mexiletine, and tocainide. Lidocaine is not reported with significant gastrointestinal side effects.

Phenytoin

Phenytoin is derived from hydantoin and is commonly used for seizure treatment. As the drug has an effect on ion channels of the cardiac membrane, it can be used as antiarrhythmic. Phenytoin is mainly metabolized and eliminated by the liver and has a narrow therapeutic window.

Phenytoin can rarely cause both acute and chronic pancreatitis. A proposed mechanism for chronic pancreatitis is the chronic induction of P450 and usually develops over years. Acute pancreatitis usually resolves with discontinuation of the drug [13].

Phenytoin is a liver enzyme inducer and can affect the metabolism of other drugs. Phenytoin can cause both acute and chronic liver damage. Liver injury can be cholestatic, cytotoxic, or mixed. Literature shows hypersensitivity is a cause of liver toxicity in over 70% cases. It can also cause irreversible liver damage associated with necrosis. A proposed mechanism is direct cytotoxic effects of toxic metabolites. Phenytoin is an aromatic antiepileptic drug and the drug metabolites cause oxidative stress, which results in hepatotoxicity [14]. There is no defined therapy, and the drug should be discontinued. Use of N-acetylcysteine is recommended in cases with severe liver damage. Also, patients with severe hepatic damage with coagulopathy should be referred to liver transplant centers. It can worsen the hepatotoxic effects caused by acetaminophen overdose (Table ) [15].

Table 4

Comparison of Cases of Phenytoin-induced Hepatotoxicity

References Age (Years)/ Sex Symptoms, signs and labs Duration of Drug Use Outcome
  Repeat Exposure
Roy, et al. [16] 52/Female Elevated serum aminotransferases 11 years Liver biopsy showed chronic persistent hepatitis. Liver functions improved after discontinuation of the drug. Etiology confirmed by rechallenge
Brackett and Bloch [17]  55/Female Elevated liver enzymes Unknown Liver enzymes improved after discontinuation of acetaminophen. Phenytoin predisposed acetaminophen toxicity Phenytoin continued.
Suchin, et al. [15] 22/Male Hepatic encephalopathy, acute renal failure, elevated liver enzymes Unknown Hemodialysis initiated and liver transplantation done, explant showed hepatic necrosis. Phenytoin worsened the acetaminophen-induced hepatotoxicity Unknown
Altuntas, et al. [18] 47/Female Exfoliative dermatitis, increase in liver enzymes with a cholestatic pattern, eosinophilia 25 days Liver biopsy consistent with drug-induced hepatitis; liver functions improved three weeks after discontinuation of phenytoin No

Mexiletine and Tocainide

Mexiletine have has the similar structure as lidocaine and acts with the similar mechanism. At the beginning, it was used as an analgesic and is now proved effective for management of ventricular arrhythmias. Mexiletine is reported to cause esophagitis and esophageal ulcers. Cases with esophageal ulcers are treated with acid suppression. Prevention is recommended, specifically, taking the drug in the upright position with a significant amount of water [19].

Tocainide is a lidocaine analogue and has a similar electrophysiological effect. Tocainide can rarely cause hepatitis; a case with granulomatous hepatitis has been reported [20].

Class 1c

Class 1c drugs include flecainide and propafenone.

Flecainide and Popafenone

Flecainide is used for supraventricular arrhythmias as atrial fibrillation. Flecainide rarely causes gastrointestinal side effects. A case of hepatitis caused by flecainide has been reported. The assumed mechanism of hepatotoxicity was an allergic reaction, and the liver enzymes improved after withdrawal of drug [21].

Propafenone has a beta blocker effect and can cause bradycardia. It is primarily metabolized by the liver. There are a handful of cases of propafenone-induced hepatotoxicity; toxicity can be hepatocellular or cholestatic. Liver functions improve with discontinuation of the drug [22].

Class 2

Class 2 drugs include beta blockers, such as propranolol, metoprolol, atenolol, esmolol, and acebutolol. 

Beta-adrenergic Receptor Blockers

Beta blockers are commonly used for hypertension, arrhythmias, migraine, glaucoma, and anxiety. Beta blockers decrease mortality in patients with atrial fibrillation with or without heart failure. Selective beta-adrenergic blockers are used for atrial and ventricular arrhythmias. Beta blockers have a wide therapeutic index but their use is associated with various side effects.

Although very rare, atenolol, carvedilol, and metoprolol can cause hepatotoxicity as evident in case reports but the etiology is unknown. Atenolol-associated hepatotoxicity is observed in very few cases, liver biopsy shows inflammatory infiltrate suggestive of immune-mediated process and cases improved with discontinuation of the drug (Table ) [23]. The study by Packer, et al. showed that 0.3% of patients of carvedilol developed abnormal liver functions leading to discontinuation of drug [24]. There is only one case of metoprolol-induced hepatotoxicity. A proposed mechanism was poor oxidation of the drugs debrisoquine and perhexiline [25].

Table 5

Comparison of beta blocker hepatotoxicity cases

Reference
 
Drug
 
Age (Years)/ Sex
 
Symptoms, signs and labs
 
   Outcome
  Repeat Exposure
Kootte, et al. [26] Sotalol 68/Female Elevated Liver enzymes Liver functions Normalized in five months after discontinuation of the drug. Unknown
Hagmeyer and Stein [27] Carvedilol 40/Male Pruritis, elevated serum transaminases Carvedilol was discontinued, symptoms improved with hydroxyzine. The drug was discontinued and liver enzymes improved after three weeks. One year later, the patient was started on metoprolol and developed pruritus in 10 days and the drug was stopped. Liver enzymes remained normal.
Dumortier, et al. [23]
 
Atenolol
 
57/Female
 
Asthenia and elevated liver enzymes Liver biopsy showed portal and centrilobular inflammation. After receiving steroids, liver function tests improved but were still elevated; repeat biopsy showed necrosis in centrilobular areas with pigmented macrophages. Liver function tests normalized two months after discontinuation of atenolol. Control liver biopsy in seven months showed disappearance of centrilobular lesions. No

Propranolol can be a risk factor for ischemic colitis if a patient is on multiple antihypertensive medications. There is a case where the patient was on nicardipine hydrochloride, propranolol hydrochloride, and digoxin for hypertension; she developed ischemic colitis post-colonoscopy and clinically improved with conservative management [28].

Class 3

Class 3 drugs include amiodarone, sotalol, dronedarone, and dofetilide.

Amiodarone

Amiodarone has a similar structure as thyroid hormone. It is a lipophilic drug and can deposit in fat tissues and liver. It is metabolized slowly, so its effects take longer to resolve. As discussed earlier, amiodarone has multiple class actions. Long-term use can cause extracardiac adverse effects as pulmonary toxicity, thyroid dysfunction, corneal deposits, and liver toxicity [29].

Hepatotoxicity ranges from asymptomatic elevated transaminases (25%) to severe liver damage (1% – 3%). Asymptomatic abnormal liver function tests (LFT) usually resolve with dose reduction or stopping the drug. Liver toxicity has been observed with both oral and IV drugs. The mechanism of liver damage with amiodarone is unclear. It could be immune-mediated hepatocyte damage with free radical formation. Damage secondary to parenteral amiodarone may be due to solvent Polysorbate 80. Polysorbate 80 is short-acting and liver function improves quickly after discontinuation of parenteral amiodarone [29]. In patients where hepatotoxicity due to amiodarone infusion is seen, oral amiodarone is safe to continue (Table ). The North American Society of Pacing and Electrophysiology (NASPE) recommends the monitoring of LFT every six months after a baseline check at the time of starting the amiodarone [30].

Table 6

Comparison of a Few Case Reports of Amiodarone-induced Hepatitis in the Literature

 
References
 
Age (Years)/ Sex
 
Symptoms, Signs and Labs
 
Duration
 
                                                  Outcome
  Repeat Exposure
Singhal, et al.  [31] 79/Male Coffee ground emesis, lethargy, ascites, spider nevi, gynecomastia, palmar erythema 33 months Cirrhosis and extensive fibrosis confirmed on liver biopsy. Amiodarone was discontinued. The patient developed renal failure, heart failure, hepatic encephalopathy and died in three months. No
Rizzioli, et al. [32] 79/Female Liver function tests increased acutely after the start of amiodarone infusion One day Amiodarone infusion was stopped, transaminases started to decrease. Progressive congestive heart failure led to death on same admission. No
Kang, et al. [33] 75/Male Nausea, vomiting, and polyneuropathy for three months and mildly elevated liver enzymes 17.8 months Liver biopsy showed microvesicular steatosis, foam cells, and Mallory bodies. Amiodarone was discontinued; liver enzymes improved on day three and symptoms slowly improved. No
Lahbabi, et al. [34] 29/Female Significantly elevated enzymes acutely after starting amiodarone infusion 24 hours Amiodarone infusion was stopped and replaced by oral amiodarone. Liver functions improved gradually. Oral amiodarone continued; liver function tests after two months were normal
Fonesca, et al. [29] 88/Male Significantly elevated liver enzymes after start of amiodarone infusion with thrombocytopenia and acute kidney injury 18 hours Amiodarone infusion was stopped; liver and renal functions gradually normalized. Oral amiodarone was restarted on day four at lower dose and liver functions were normal on follow-up
Chen and Wu [35] Unknown Acutely elevated liver enzymes after starting amiodarone infusion 24 hours Amiodarone infusion was stopped; liver enzymes normalized. Oral amiodarone was started on lower dose and hepatotoxicity did not occur on follow-up

A large retrospective cohort study conducted in Taiwan showed that use of amiodarone is associated with malignant neoplasm of the liver and intrahepatic bile ducts (MNLIHD) in a dose-dependent manner. Malignancy is common in cases with comorbidities, such as diabetes, chronic liver disease, cirrhosis, hepatitis C, hepatitis B, and alcoholism (Table ) [36].

Table 7

Odds Ratio with Confidence Interval of 95% for Malignant Neoplasm of the Liver and Intrahepatic Bile Ducts (MNLIHD) Associated with Amiodarone and Other Antiarrhythmics

Modified from Yun-Ping, et al. [36]

Medications MNLIHD odds ratio (confidence interval 95%)
Amiodarone 1.6 (1.45 – 1.77)
Mexiletine 1.07 (0.98 – 1.18)
Propafenone 0.97 (0.85 – 1.11)
Quinidine 1.32 (0.91 – 1.93)
Procainamide 0.97 (0.71 – 1.33)

Amiodarone can rarely cause acute pancreatitis as there are few case reports in the literature. A case control population study by Lai, et al. showed the current use of amiodarone increases the risk of acute pancreatitis (Table ) [37]. The exact mechanism of pancreatitis caused by amiodarone is unknown. Proposed mechanisms are direct toxicity caused by amiodarone and its metabolite, mono-N-desethylamiodarone, due to its lipophilic nature. Amiodarone is metabolized by P450, and pancreatitis can be caused by drug-drug interaction. The case reports show improvement of pancreatitis symptoms with discontinuation of the drug (Table ).

Table 8

Amiodarone-associated Acute Pancreatitis

Modified from Lai, et al. [37]

Amiodarone use Acute pancreatitis adjusted odds ratio (confidence interval 95%)
Current Use 5.21 (3.22 – 8.43)
Recent Use 1.18 (0.32 – 4.35)
Past Use 1.42 (0.99 – 2.03)

Table 9

Summary and Comparison of Cases of Amiodarone-induced Pancreatitis

References Age (Years)/ Sex Symptoms, signs and labs Duration Outcome
  Repeat Exposure
Bosch and Bernadich  [38] 46/Female Nausea, vomiting, epigastric pain, elevated lipase Four days Intravenous fluids were given; symptoms resolved after discontinuation of the drug. Procainamide was started. Procainamide was stopped and amiodarone was started at low dose 100 mg per day. After three days, the patient had recurrence of symptoms with elevated amylase and lipase. Amiodarone was stopped and procainamide was restarted.
Famularo, et al. [39] 80/Male Epigastric pain, vomiting, distended abdomen, elevated amylase, and lipase Five days Amiodarone dose was reduced to 200 mg daily from loading dose; symptoms and serum lipase levels improved after three days. Rechallenge with a high dose of amiodarone was not performed and continued with 200 mg.
Chen, et al. [40] 66/Female Epigastic pain, loss of appetite, and elevated lipase Three months Abdominal pain persisted even after three weeks of conservative management. All causes ruled out. Amiodarone was substituted with propafenone; symptoms resolved and lipase gradually trended down No

Sotalol

Sotalol is a non-selective beta blocker and can be used for the treatment of atrial fibrillation, ventricular tachycardia, premature ventricular contractions, and supraventricular tachycardia. Sotalol is a hydrophilic drug and not metabolized by the liver; still, one case of severe chronic hepatitis has been reported. The mechanism of liver injury is unknown. Patient symptoms improved and liver functions normalized on discontinuation of the drug (Table ) [26].

Dronedarone

Dronedarone is a newer drug and has a structure similar to amiodarone. The drug is used for atrial fibrillation and atrial flutter. Dronedarone can cause hepatotoxicity with mitochondrial damage. A study on rat liver cells explained the mechanism, as it inhibited the electron transport chain and beta oxidation; this caused increased production of reactive oxygen species (ROS), which led to apoptosis and mitochondrial damage [41]. There are a few cases of severe toxic hepatitis. Two of the hepatic failure cases were treated with the emergent liver transplant (Table ) [42].

Table 10

Summary of Cases of Dronedarone-induced Hepatotoxicity

ICU: intensive care unit

Reference Age (Years)/ Sex Symptoms, Signs and Labs Duration Outcome
  Repeat Exposure
Del Pozo Ruis, et al. [43] 75/Male Nausea, vomiting, abdominal pain, elevated liver enzymes Four days Patient developed fulminant liver failure, dronedarone was discontinued. Liver functions improved after seven days of discontinuation and ICU monitoring No
Jahn, et al. [42] 69/Female Elevated liver enzymes Unknown Acute liver failure resolved after discontinuation of the drug. Unknown
Rizkallah, et al. [44] 85/Male Nausea and elevated liver enzymes One day Drug was discontinued after three doses; the patient developed multiorgan failure and died on day 8. No

Class 4

Class 4 drugs include calcium channel blockers (CCB), such as verapamil and diltiazem.

Verapamil

Verapamil is commonly used for supraventricular tachycardia, hypertension, and angina. Verapamil not only acts on the calcium channel in the heart muscle but also on vascular and gastrointestinal smooth muscle. The most common adverse effect of verapamil is constipation ranging from 6-8%. The mechanism is likely slow transit time in the colon and less likely upper gastrointestinal tract. Constipation is sometimes significant enough to discontinue the drug. Verapamil was also reported to aggravate a pseudo-obstruction in a case report, which improved once verapamil was discontinued [45].

A prospective cohort study showed that CCBs used for hypertension, including verapamil and diltiazem, increased the risk of gastrointestinal hemorrhage in the elderly population. Therefore, CCBs need to be used with caution in an elderly population with risks of gastrointestinal hemorrhage [46]. Rarely, verapamil can lead to idiosyncratic hepatitis. Symptoms and liver functions improve with discontinuation of drug [47].

Diltiazem

Diltiazem is commonly used for supraventricular tachycardia, hypertension, and angina. The drug has an extensive first-pass hepatic metabolism. CCBs are a weak inhibitor of CYP 3A4 and increase serum levels of medications metabolized by CYP 3A4. Intravenous infusion of diltiazem can drop the blood pressure and can lead to hypoxic liver injury. There was a case of hypoxic hepatitis in a patient who was started on diltiazem for atrial fibrillation. Liver congestion due to heart failure can also be a contributing factor. In this case of hypoxic hepatitis, the diltiazem infusion was stopped; anticoagulation was held initially because of liver toxicity-induced coagulopathy [48].

A case of paralytic ileus was reported in a patient taking diltiazem for atrial fibrillation and rapidly improved after discontinuation of the drug. The proposed mechanism was decreased gastrointestinal motility due to inhibition of calcium channels in GI smooth muscles [49].

Digoxin

Digoxin is one of most commonly used antiarrhythmics. It is also used in patients with atrial fibrillation and heart failure. Digoxin can cause nonspecific gastrointestinal side effects, such as nausea and vomiting.

A case control study by Lai, et al. showed an increased odds ratio of acute pancreatitis in patients with active digoxin use, and risk was further increased in a patient with chronic kidney disease as 70% of digoxin is normally excreted from the kidneys. The Food and Drug Administration (FDA) has reported 0.2% of cases of acute pancreatitis from 1997 to 2012 in patients on digoxin. The exact pathophysiology was not known; it could have been due to a drug-drug interaction. The proposed mechanism was that digoxin causes hypomagnesemia, which leads to increased glycosaminoglycan levels in the pancreas and can lead to pancreatitis [50].

Adenosine

Adenosine is a natural nucleoside, is given as an intravenous infusion, and has a very short half-life. It is used for the treatment of paroxysmal supraventricular tachycardia. Because of its short half-life, adenosine is not associated with any major adverse effects.

Differences, similarities, and which is better for you

Drug overview & main differences | Conditions treated | Efficacy | Insurance coverage and cost comparison | Side effects | Drug interactions | Warnings | FAQ

Carvedilol and metoprolol are prescription medications used to treat high blood pressure (hypertension) and heart problems, such as heart failure. These medications can also be used to reduce the risk of death after a heart attack (myocardial infarction).

Both carvedilol and metoprolol are classified as beta-blockers, also known as beta-adrenergic blocking agents. They work by blocking beta receptors, which block the effects of norepinephrine and epinephrine in the heart and blood vessels. Beta-blockers help lower blood pressure and slow heart rate to relieve stress on the heart.

Carvedilol and metoprolol are both generic medications. Although they share similarities, they also have differences in dosage, formulation, and side effects.

What are the main differences between carvedilol and metoprolol?

Carvedilol is considered a non-selective beta-blocker. This means that carvedilol can block both beta-1 receptors and beta-2 receptors. Beta-1 receptors are found in the heart while beta-2 receptors are primarily found in the smooth muscles. Carvedilol also blocks alpha receptors in the arteries, which helps lower blood pressure.

Carvedilol is the generic name for Coreg. It is usually taken as a 3.125 mg, 6.25 mg, 12.5 mg, or 25 mg oral tablet twice daily. Carvedilol is also available in an extended-release form (Coreg CR) that can be taken once daily.

Metoprolol is a beta-1 selective blocker that primarily blocks the beta-1 receptors in the heart. However, it also blocks beta-2 receptors, although to a lesser degree. Selective beta-blockers may have slightly different effects compared to non-selective beta-blockers.

Metoprolol comes in two different salt forms: metoprolol tartrate and metoprolol succinate. Metoprolol tartrate, also known by the brand name Lopressor, is an immediate-release oral tablet that comes in strengths of 25 mg, 37.5 mg, 50 mg, 75 mg, and 100 mg. Metoprolol succinate, also known by the brand name Toprol XL, is an extended-release oral tablet that comes in strengths of 25 mg, 50 mg, 100 mg, and 200 mg.

RELATED: Metoprolol vs. Atenolol

Main differences between carvedilol and metoprolol
Drug class Beta-blocker Beta-blocker
Brand/generic status Brand and generic version available Brand and generic version available
What is the brand name? Coreg (immediate-release)
Coreg CR (extended-release)
Lopressor (immediate-release)
Toprol XL (extended-release)
What form(s) does the drug come in? Oral tablet Oral tablet
What is the standard dosage? Carvedilol (immediate-release): 25 mg twice daily
Carvedilol (extended-release): 10 to 80 mg once dailyDosage depends on the condition being treated
Metoprolol tartrate (immediate-release): 50 to 100 mg twice daily
Metoprolol succinate (extended-release): 25 to 100 mg once dailyDosage depends on the condition being treated
How long is the typical treatment? Long term Long term
Who typically uses the medication? Adults Adults

Conditions treated by carvedilol and metoprolol

Both carvedilol and metoprolol succinate are FDA approved to treat heart failure caused by ischemia, hypertension, or cardiomyopathy. Both beta-blockers are also approved to treat hypertension.

Beta-blockers are typically used in addition to other medications like angiotensin-converting enzyme (ACE) inhibitors and diuretics. Lowering systolic or diastolic blood pressure can help lower the risk of a cardiovascular event like a heart attack or stroke.

Carvedilol and metoprolol can be used to reduce the risk of morbidity and mortality following a heart attack. These medications can also treat left ventricular dysfunction after a heart attack.

Both medications can be used to treat angina pectoris, or chest pain, caused by coronary heart disease. Carvedilol or metoprolol may be prescribed to reduce angina attacks and improve exercise capabilities in those with heart disease or heart failure.

Off-label uses of carvedilol and metoprolol include the treatment of arrhythmias, or abnormal heart rhythms, such as atrial fibrillation.

Heart failure Yes Yes
Hypertension Yes Yes
Myocardial infarction Yes Yes
Angina pectoris Off-label Yes
Arrhythmia Off-label Off-label

Is carvedilol or metoprolol more effective?

The Carvedilol or Metoprolol European Trial (COMET) was a randomized controlled trial that compared carvedilol and metoprolol in patients with chronic heart failure. The trial was conducted over almost five years in more than 1,500 patients. Results, which were published in the Lancet, showed an all-cause mortality of 34% for carvedilol versus 40% for metoprolol. In other words, carvedilol was found to increase survival in heart failure patients more than metoprolol.

A 2021 comparative study from the American Journal of Cardiology found that there was no significant difference in survival rates after a heart attack with carvedilol versus metoprolol in patients with a left ventricular ejection fraction over 40%. However, in those with a left ventricular ejection fraction less than 40%, carvedilol may be a more effective beta-blocker.

According to a meta-analysis, carvedilol and metoprolol are similar in effectiveness when used after a heart attack. When compared to placebo, both beta-blockers were found to significantly reduce cardiovascular events and subsequent heart attacks. However, no significant benefits on all-cause mortality, revascularization, and hospitalization were found for either carvedilol or metoprolol.

Both carvedilol and metoprolol can be effective treatment options. Treatment may be personalized based on the treated condition, potential side effects, and cost. Consult a healthcare provider on the best treatment for you.

Coverage and cost comparison of carvedilol vs. metoprolol

Carvedilol is covered by most Medicare and insurance plans. The copay will depend on the plan’s formulary and coverage. The average cash price of carvedilol is around $160. Even with insurance, carvedilol can be expensive. Using a SingleCare discount card for carvedilol may be able to lower the out-of-pocket cost to around $5.

Metoprolol is also covered by most Medicare and insurance plans. Consult your pharmacist or insurance plan to find out what the copay for metoprolol would be. The average cash price of metoprolol is around $168. A SingleCare discount card for metoprolol tartrate or metoprolol succinate could help you save significantly on the cost of the prescription.

Typically covered by insurance? Yes Yes
Typically covered by Medicare Part D? Yes Yes
Quantity 60 tablets (6.25 mg) 60 tablets (25 mg)
Typical Medicare copay $0–$15 $0–$65
SingleCare cost $4+ $4+

Common side effects of carvedilol vs. metoprolol

Carvedilol and metoprolol share similar side effects. The most common side effects of carvedilol are dizziness, fatigue, weakness, low blood pressure (hypotension), diarrhea, high blood sugar (hyperglycemia), slow heart rate (bradycardia), and weight gain. The most common side effects of metoprolol tiredness, dizziness, diarrhea, itching, and depression.

Serious side effects of carvedilol and metoprolol may occur, such as allergic reactions, dangerously low blood pressure, and bronchospasms or shortness of breath. Seek immediate medical attention if you experience severe rash, swelling, or trouble breathing after taking carvedilol or metoprolol.

Side effect Applicable? Frequency Applicable? Frequency
Dizziness Yes 32% Yes 10%
Fatigue Yes 24% Yes 10%
Hypotension Yes 9% Yes 1%
Diarrhea Yes 12% Yes 5%
Hyperglycemia Yes 12% Yes *
Weakness Yes 7% Yes 10%
Slow heart rate Yes 9% Yes 3%
Weight gain Yes 10% Yes *
Shortness of breath Yes * Yes 3%
Cold extremities No Yes 1%
Depression Yes <1% Yes 5%
Itching Yes <1% Yes 5%

*not reported
Frequency is not based on data from a head-to-head trial. This may not be a complete list of adverse effects that can occur. Please refer to your doctor or healthcare provider to learn more.
Source: DailyMed (Carvedilol), DailyMed (Metoprolol)

Drug interactions of carvedilol vs. metoprolol

Both carvedilol and metoprolol can lower blood pressure and slow heart rate. Therefore, they can interact with other medications that have similar effects. Both carvedilol and metoprolol, like most beta-blockers, can interact with blood pressure lowering agents, monoamine oxidase inhibitors (MAOIs), and calcium channel blockers. Taking these medications together can increase the risk of dangerously low blood pressure or slowed heart rate.

Carvedilol and metoprolol are mainly processed in the liver by the CYP2D6 enzyme. Drugs that inhibit this enzyme can interact with carvedilol and metoprolol, which can lead to increased levels of carvedilol or metoprolol. Increased blood levels of carvedilol or metoprolol can lead to an increased risk of side effects.

Beta-blockers may increase the blood-sugar-lowering effects of oral hypoglycemic medications like glipizide, metformin, or insulin. Caution should be advised when these medications are taken together.

See the table below for other possible drug interactions.

Clonidine
Guanethidine
Reserpine
Alpha-adrenergic agents Yes Yes
Selegiline
Isocarboxazid
Phenelzine
Monoamine oxidase inhibitors (MAOIs) Yes Yes
Amlodipine
Nifedipine
Calcium channel blockers Yes Yes
Fluvoxamine
Fluoxetine
Chlorpromazine
Quinidine
Ritonavir
Terbinafine
CYP2D6 inhibitors Yes Yes
Glipizide
Metformin
Rosiglitazone
Sitagliptin
Oral hypoglycemics Yes Yes
Dihydroergotamine
Ergotamine
Ergot alkaloids Yes Yes
Hydralazine Vasodilators Yes Yes
Digoxin Cardiac glycosides Yes Yes
Cyclosporine Immunosuppressants Yes Yes
Dipyridamole Platelet inhibitors Yes Yes

Consult a healthcare professional for other possible drug interactions

Warnings of carvedilol and metoprolol

Beta-blockers should not be abruptly discontinued. Instead, they should be gradually tapered to lower doses. There may be an increased risk of worsened coronary artery disease, angina, myocardial infarction, and ventricular arrhythmias after abruptly discontinuing a beta-blocker.

Beta-blockers can mask the symptoms of hypoglycemia or hyperthyroidism, such as fast heart rate. Diabetic patients and those with thyroid problems may need to use caution with beta-blockers.

Both carvedilol and metoprolol carry warnings of bronchospasm, especially in those with chronic obstructive pulmonary disease (COPD) or other breathing problems. However, studies have shown that beta-blockers may actually reduce exacerbations and increase survival in those with COPD.

Tell your healthcare provider if you have a history of congestive heart failure, asthma, slow heartbeat, liver problems, or allergic reactions to ingredients in carvedilol or metoprolol. Consult a healthcare provider for other warnings and precautions associated with the use of carvedilol or metoprolol.

Frequently asked questions about carvedilol vs. metoprolol

What is carvedilol?

Carvedilol is a beta-blocker medication that is used to treat heart failure and hypertension. It can also be used to increase survival after a heart attack. Carvedilol comes in immediate-release and extended-release forms. It was FDA approved in 1995.

What is metoprolol?

Metoprolol is a beta-blocker medication that can treat heart failure, hypertension, and chronic chest pain. Metoprolol succinate, the extended-release form of metoprolol is also FDA approved to treat heart failure. Immediate-release metoprolol contains metoprolol tartrate. Metoprolol was initially FDA approved in 1978.

Are carvedilol and metoprolol the same?

Both carvedilol and metoprolol are beta-adrenergic receptor blockers, or beta-blockers. They are both used to treat chronic heart failure and hypertension. However, they contain different active ingredients and work in slightly different ways. Carvedilol is a non-selective beta-blocker and metoprolol is a beta-1 selective beta-blocker.

Is carvedilol or metoprolol better?

Carvedilol and metoprolol are both highly effective medications when compared to placebo. Carvedilol may be better for certain patients with heart failure, according to the COMET trial. Carvedilol and metoprolol are similarly effective for increasing survival after a heart attack. Guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) recommend the use of either carvedilol, metoprolol succinate, or bisoprolol for patients with heart failure with reduced ejection fraction. Consult a healthcare provider for the best treatment option for your specific condition.

Can I use carvedilol or metoprolol while pregnant?

Beta-blockers are commonly used in pregnant women with heart conditions. However, there is no evidence that suggests that beta-blockers are completely safe or harmful during pregnancy. Both carvedilol and metoprolol may carry a risk of fetal harm. Consult a healthcare provider for medical advice before using a beta-blocker during pregnancy.

Can I use carvedilol or metoprolol with alcohol?

There may be an increased risk of side effects when combining a beta-blocker with alcohol. Taking carvedilol or metoprolol with alcohol may increase the risk of drowsiness, dizziness, and low blood pressure. Alcohol may also decrease the effectiveness of beta-blockers.

Does carvedilol lower blood pressure more than metoprolol?

Carvedilol may lower blood pressure more than metoprolol. This is because carvedilol has vasodilating properties that help relax blood vessels and lower blood pressure. No studies have directly compared the blood pressure lowering effects of carvedilol and metoprolol. However, carvedilol may help prevent cardiovascular events more than metoprolol in hypertensive patients.

Can you switch from metoprolol to carvedilol? / Is it safe to switch beta blockers?

It is generally safe to switch beta-blockers if needed or as recommended by a healthcare provider. Depending on the beta-blocker, the switch can be immediate or the dose of the initial beta-blocker can be weaned while the dose of the new beta-blocker is gradually increased to a target dose. Follow-up visits may be needed to assess the effectiveness of the new beta-blocker.

What is a good replacement for carvedilol?

The best replacement for carvedilol will depend on the condition being treated. There are only two medications FDA-approved to treat heart failure other than carvedilol: bisoprolol and metoprolol succinate. Other examples of beta-blockers include atenolol, nebivolol, and propranolol.

Is there a better beta blocker than metoprolol?

Possible alternatives to metoprolol succinate for treating heart failure include bisoprolol and carvedilol. The better beta blocker will be the one that works best for you. Other factors may play a role in choosing a beta blocker, such as cost, side effects, and other medications you may be taking.

Atenolol: for high blood pressure, irregular heartbeats and chest pain

You’ll usually take atenolol once or twice a day.

When you start taking atenolol, your doctor may advise you to take your first dose before bedtime because it can make you feel dizzy.

After the first dose, if you do not feel dizzy, you can take your medicine in the morning.

If you’re taking atenolol twice a day, you’ll usually have 1 dose in the morning and 1 dose in the evening.

It’s a good idea to leave 10 to 12 hours between doses if you can.

Do not stop taking atenolol suddenly, especially if you have heart disease. This can make your condition worse.

If you want to stop taking your medicine, speak to your doctor. They may recommended reducing your dose gradually over a few weeks.

Dosage

How much you take depends on why you need atenolol.

For high blood pressure – the usual dose is 25mg to 50mg taken once a day.

For angina (chest pain) – the usual dose is 100mg taken once a day, or split into 2 50mg doses.

For irregular heartbeats (arrhythmia) – the usual dose is 50mg to 100mg taken once a day.

For migraine – the usual dose is 25mg to 100mg taken twice a day. Doctors sometimes prescribe atenolol for migraine, but it’s not officially approved for preventing it.

For children taking atenolol, your child’s doctor will work out the right dose by using their weight and age.

How to take it

Atenolol does not usually upset your tummy, so you can take it with or without food. It’s best to do the same each day.

Swallow the tablets whole with a drink of water.

If you find them difficult to swallow, some brands have a score line to help you break the tablet in half. Check the information leaflet for your brand to see if you can do this.

If you’re taking atenolol as a liquid, it’ll come with a plastic syringe or spoon to help you measure out the right dose.

If you do not have one, ask your pharmacist for one. Do not use a kitchen teaspoon as it will not give you the right amount of medicine.

What if I forget to take it?

If you forget to take a dose of atenolol, take it as soon as you remember, unless it’s nearly time for your next dose. In this case, just leave out the missed dose and take your next dose as normal.

Never take 2 doses at the same time. Do not take an extra dose to make up for a forgotten one.

If you often forget doses, it may help to set an alarm to remind you.

You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What if I take too much?

The amount of atenolol that can lead to an overdose varies from person to person.

If you take more than the prescribed dose, your heart rate may slow down and you may find it difficult to breathe. It can also cause dizziness and trembling.

If you need to go to hospital, do not drive yourself. Get someone else to drive you or call for an ambulance.

Take the atenolol packet or leaflet inside it, plus any remaining medicine, with you.

Find your nearest A&E

High Blood Pressure | FDA

There are various FDA-approved products that are currently available to treat high blood pressure. Learn more about your options and use this information to help you talk to your healthcare provider about your blood pressure medicine. You will also find some general information to help you use your medicine wisely.

High blood pressure is a serious illness.
High blood pressure is often called a “silent killer” because you can have it and not know it. You may not feel sick at first. Over time, if you do not get treated for high blood pressure, you can get very sick or even die. 

High blood pressure can cause:

  • Kidney failure
  • Stroke
  • Blindness
  • Heart attacks
  • Heart disease

There is good news. There are life-saving medicines you can take every day to help control your high blood pressure. If you eat healthy foods, exercise, and take your medicine every day, you can help control your blood pressure.

  • Take your blood pressure medicine.
  • It is important to take your blood pressure medicine every day. Take your medicine even when your blood pressure comes down… even when you do not feel bad. Do not stop taking your medicine until your healthcare provider says that it is OK.
  • Many people who take high blood pressure medicine do not get any side effects. Like all medicines, high blood pressure medicines can sometimes cause side effects. You may have common problems like headaches, dizziness, or an upset stomach. These can be bothersome to how you feel every day but often lessen after the first few weeks of taking the medicine. If you find they continue to be bothersome to you, talk to your healthcare provider.

Understanding Your Blood Pressure: What Do the Numbers Mean? 
Blood pressure is the force of your blood pushing against the walls of your arteries as your heart pumps blood. High blood pressure, or hypertension, is when this force against your artery walls is too high. The higher your blood pressure levels, the more risk you have for other health problems such as heart disease, heart attack, and stroke.

When you have your blood pressure taken, you are told two numbers; for example, 120/80. Both numbers are important. The first (or top) number is your pressure when your heart beats (systolic pressure). The second number is your pressure when your heart relaxes (diastolic pressure). If the measurement reads 120 systolic and 80 diastolic, you would say, “120 over 80.” A normal blood pressure level is usually considered to be less than 120/80.

Talk with your healthcare provider about your numbers and how you can manage your blood pressure.

High Blood Pressure and Pregnancy
Some women have high blood pressure during pregnancy. This can put the mother and her baby at risk for problems during the pregnancy and after delivery. High blood pressure sometimes can be severe, which may lead to low birth weight or preterm birth. High blood pressure during pregnancy can raise your risk of high blood pressure in the future.

There are different types of high blood pressure during pregnancy.

Gestational hypertension is high blood pressure that you develop while you are pregnant. It starts after you are 20 weeks pregnant. In many cases, gestational hypertension does not harm you or your baby, and it goes away within 12 weeks after childbirth. Some women with gestational hypertension develop preeclampsia.

Chronic hypertension is high blood pressure that started before the 20th week of pregnancy or before you became pregnant. Some women may have had high blood pressure long before becoming pregnant but were unaware until they got their blood pressure checked at their prenatal visit. Sometimes chronic hypertension can also lead to preeclampsia. 

Preeclampsia is a sudden increase in blood pressure after the 20th week of pregnancy and may include protein in the urine and very high blood pressure. It usually happens in the last trimester. In rare cases, symptoms may not start until after delivery. This is called postpartum preeclampsia. Preeclampsia may cause damage to some of your organs, such as your liver or kidneys. Preeclampsia can be serious or even life-threatening for both you and your baby.

The most important thing to do is talk with your healthcare provider about any blood pressure problems so you can get the right treatment and control your blood pressure—before you get pregnant. Getting treatment for high blood pressure is important before, during, and after pregnancy to decrease risks to you and your baby.

For more information about high blood pressure and pregnancy, go to https://www.cdc.gov/bloodpressure/pregnancy.htm.

Types of High Blood Pressure Medicines

You can use this information to help you talk to your healthcare provider about your blood pressure medicine.

  • Ask your healthcare provider about the benefits and risks of taking your medicine. This webpage only talks about some of the risks.
  • Tell your healthcare provider about any problems you are having. Your healthcare provider will help you find the medicine that is best for you.
  • Be sure to tell your healthcare provider if you are pregnant, nursing, or planning to get pregnant. Ask your healthcare provider to tell you about the benefits and risks of taking blood pressure medicine when you are pregnant.

The different kinds of blood pressure medicines are listed below. The medicines are listed in groups. The brand names and generic names are given for the medicines in each group.


Angiotension-Converting Enzyme (ACE) Inhibitors

Generic Name Brand Name
benzapril Lotensin
captopril Generic Medicine Only
enalapril Epaned and Vasotec
fosinopril Generic Medicine Only
lisinopril Prinivil, Qbrelis, and Zestril
moexipril Generic Medicine Only
perindopril Generic Medicine Only
quinapril Accupril
ramipril Altace
trandolapril Generic Medicine Only

ACE Inhibitors: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have kidney or liver problems, diabetes, heart problems, or a history of angioedema, talk to your healthcare provider about the risks of using this medicine.
  • If you are taking aliskiren, diabetes medicines, diuretics (water pills), gold injections, lithium, neprilysin inhibitors (such as sacubitril), mTOR inhibitors, nonsteroidal anti-inflammatory drugs, or other medicines, talk to your healthcare provider about the risks of using this medicine.

Common Side Effects

  • Cough
  • Dizziness
  • Feeling tired
  • Headache
  • Problems sleeping

Warning Signs

Seek medical attention if you have any of these signs:

  • Abdominal pain
  • Chest pain
  • Fast heartbeat
  • Jaundice
  • Problems breathing or swallowing
  • Signs of infection (e.g., sore throat, fever)
  • Swelling in the face, eyes, lips, tongue, or legs

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Beta Blockers

Generic Name Brand Name
acebutolol Generic Medicine Only
atenolol Tenormin
betaxolol Generic Medicine Only
bisoprolol Generic Medicine Only
carvedilol Coreg
carvedilol phosphate Coreg CR
labetalol Trandate
metoprolol succinate Kapspargo Sprinkle and Toprol-XL
metoprolol tartrate Lopressor
nadolol Corgard
nebivolol Bystolic
pindolol Generic Medicine Only
propranolol Inderal, Inderal LA, and InnoPran XL
timolol Generic Medicine Only

Beta-Blockers: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have a heart condition, kidney or liver problems, asthma, diabetes, or overactive thyroid, talk to your healthcare provider about the specific risks of using this medicine.
  • If you are taking other medicines, talk to your healthcare provider about the risks of using beta-blockers.
  • If you are planning to have cataract surgery, notify your eye doctor that you are using this medicine.
  • Do not suddenly stop taking this medicine without the advice of your healthcare provider.

Common Side Effects

  • Feeling tired
  • Upset stomach
  • Headache
  • Dizziness
  • Constipation or Diarrhea
  • Feeling lightheaded

Warning Signs

Seek medical attention if you have any of these signs:

  • Chest pain
  • Problems breathing
  • Slow or irregular heartbeat
  • Swelling in the hands, feet, ankles, or legs

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Calcium Channel Blockers

Generic Name Brand Name
amlodipine benzoate Katerzia
amlodipine besylate  Norvasc
diltiazem Cardizem CD, Cardizem LA, Cartia XT, Diltzac, Tiazac, and Taztia XT
felodipine Generic Medicine Only
isradipine Generic Medicine Only
levamlodipine Conjupri
nifedipine Adalat CC and Procardia X
nisoldipine Sular
verapamil Calan SR, Verelan, and Verelan PM

Calcium Channel Blockers: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have a heart condition, liver problems, or kidney problems, talk to your healthcare provider about the specific risks of using calcium channel blockers.
  • If you are taking cimetidine, cyclosporine, fentanyl, sildenafil, simvastatin, tacrolimus, or other medicines, talk to your healthcare provider about the risks of using this medicine.

Common Side Effects

  • Feeling drowsy
  • Headache
  • Upset stomach
  • Ankle swelling
  • Feeling flushed (warm)

Warning Signs

Seek medical attention if you have any of these signs:

  • Chest pain
  • Serious rashes
  • Swelling of the face, eyes, lips, tongue, arms, or legs
  • Fainting
  • Irregular heartbeat 

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Peripherally Acting Alpha-Adrenergic Blockers

Generic Name Brand Name
doxazosin Cardura and Cardura XL
phenoxybenzamine Generic Medicine Only
prazosin Minipress
terazosin Generic Medicine Only

Peripherally Acting Alpha-Adrenergic Blockers: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have liver problems, talk to your healthcare provider about the risks of using this medicine.
  • If you are taking other medicines, talk to your healthcare provider about the risks of using this medicine.
  • If you are planning to have cataract surgery, notify your eye doctor that you are using this medicine.

Common Side Effects

  • Dizziness
  • Feeling tired
  • Feeling light-headed
  • Vision problems
  • Decreased sexual ability

Warning Signs

Seek medical attention if you have any of these signs:

  • Chest pain
  • Fainting
  • Swelling of the hands, feet, ankles, or legs
  • Irregular heartbeat
  • Prolonged or painful erection in men

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Vasodilators

Generic Name Brand Name
hydralazine Generic Medicine Only
minoxidil Generic Medicine Only

Vasodilators: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have heart disease or kidney problems, talk to your healthcare provider about the risks of using this medicine.
  • If you are taking diuretics (water pills) or other medicines, talk to your healthcare provider about the risks of using this medicine.

Common Side Effects

  • Upset stomach
  • Dizziness
  • Growth in body hair

Warning Signs

Seek medical attention if you have any of these signs:

  • Fast heartbeat
  • Fainting
  • Chest pain
  • Problems breathing
  • Sudden weight gain
  • Swelling of the hands, feet, ankles, or legs
  • Skin tingling or numbness, skin crawling, or itching 

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Angiotension II Antagonists

Generic Name Brand Name
azilsartan Edarbi
candesartan Atacand 
irbesartan Avapro
losartan Cozaar
olmesartan Benicar 
telmisartan Micardis 
valsartan Diovan

Angiotension II Antagonists: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before you start using this medicine.
  • If you have kidney problems, liver problems, diabetes, low blood volume, or low salt in your blood, talk to your healthcare provider about the risks of taking this medicine.
  • If you are taking diuretics (water pills), aliskiren, antibiotics, cyclosporine, lithium, nonsteroidal anti-inflammatory drugs, potassium supplements, ritonavir, or other medicines, talk to your healthcare provider about the risks of taking this medicine.

Common Side Effects

  • Cough
  • Headache
  • Sore throat
  • Sinus problems
  • Heartburn
  • Dizziness
  • Diarrhea
  • Back pain

Warning Signs

Seek medical attention if you have any of these signs:

  • Problems breathing
  • Fainting
  • Severe, chronic diarrhea with significant weight loss
  • Swelling of the face, throat, lips, eyes, hands, feet, ankles, or legsr legs

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Centrally-Acting Alpha Adrenergics

Generic Name Brand Name
clonidine Catapres
clonidine Catapres–TTS-1, TTS-2, TTS-3 
(Skin Patches)
guanfacine  Generic Medicine Only

Centrally-Acting Alpha Adrenergics: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before you start using this medicine.
  • If you have heart disease, kidney problems, or liver problems, talk to your healthcare provider before using this medicine.
  • If you are taking antidepressants, antipsychotics, or other medicines, talk to your healthcare provider about the risks of using this medicine.
  • Drinking alcohol may make side effects such as drowsiness, dizziness, or vision problems worse.
  • Be careful when driving or operating machinery.
  • Keep both used and unused skin patches out of the reach of children. Used patches still contain enough medicine to be harmful to a child. 
  • Tell your healthcare provider before you have an MRI scan if you are using the skin patch.
  • Do not suddenly stop taking this medicine without the advice of your healthcare provider.

Common Side Effects

  • Changes in vision
  • Dizziness
  • Dry eyes
  • Dry mouth
  • Headache
  • Mild skin rash, itching, or redness (close to the patch)
  • Decreased sexual ability
  • Feeling drowsy or tired

Warning Signs

Seek medical attention if you have any of these signs:

  • Allergic reaction (including hives, rash, or swelling in other parts of your body)
  • Fainting
  • Moderate-to-severe skin rash, itching, or redness
  • Slow or irregular heartbeat
  • Fever
  • Swollen ankles or feet

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Renin Inhibitors

Generic Name Brand Name
Aliskiren  Tekturna

Renin Inhibitors: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have diabetes, heart disease, or kidney problems, talk to your healthcare provider before using this medicine.
  • If you are taking water pills (diuretics), cyclosporine, high blood pressure medicines, heart medicines, nonsteroidal anti-inflammatory drugs, potassium supplements, medicines to treat a fungus, or other medicines, talk to your healthcare provider about the risks of using this medicine.

Common Side Effects

  • Cough 
  • Diarrhea
  • Feeling light-headed
  • Acid reflux
  • Rash
  • Upset stomach
  • Abdominal pain

Warning Signs

Seek medical attention if you have any of these signs:

  • Allergic reaction (difficulty breathing, hives, rash, or swelling in your whole body)
  • Fainting
  • Decreased urination
  • Gout
  • Kidney stones
  • Seizures
  • Swelling of the face, throat, lips, eyes, or tongue

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Combination Medicines

Generic Name Brand Name
aliskiren and hydrochlorothiazide Tekturna HCT
amlodipine besylate and valsartan Exforge
amlodipine besylate and benazepril Lotrel
amlodipine besylate and olmesartan Azor
amlodipine besylate and perindopril  Prestalia
amlodipine besylate and telmisartan Twynsta
amlodipine besylate, hydrochlorothiazide, and valsartan Exforge HCT
atenolol and chlorthalidone Tenoretic 50, Tenoretic 100
benazepril and hydrochlorothiazide Lotensin HCT
candesartan and hydrochlorothiazide Atacand HCT
captopril and hydrochlorothiazide Generic Medicine Only
enalapril and hydrochlorothiazide Vaseretic
fosinopril and hydrochlorothiazide Generic Medicine Only
hydrochlorothiazide and irbesartan Avalide
hydrochlorothiazide and lisinopril Zestoretic
hydrochlorothiazide and metoprolol succinate Dutoprol
hydrochlorothiazide and metoprolol tartrate Lopressor HCT
hydrochlorothiazide and olmesartan Benicar HCT
hydrochlorothiazide and quinapril Accuretic and Quinaretic
hydrochlorothiazide and telmisartan Micardis HCT
bisoprolol and hydrochlorothiazide  Ziac
hydrochlorothiazide and losartan Hyzaar
hydrochlorothiazide and metoprolol tartrate Generic Medicine Only
hydrochlorothiazide and moexipril Generic Medicine Only
amlodipine besylate, hydrochlorothiazide, and olmesartan Tribenzor
trandolapril and verapamil Tarka
hydrochlorothiazide and valsartan Diovan HCT
chlorthalidone and zilsartan  Edarbyclor

Combination Drugs: What You Should Know

These medicines are made up of two or more different kinds of blood pressure medicines. Look for the generic or brand names of these medicines on one of the other lists in this guide.

Warnings and Side Effects

The warnings and side effects for these medicines will be the same as those listed for each of the generic medicines.

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Other Combination Medicines

Generic Name Brand Name
amlodipine besylate and atorvastatin Caduet
amlodipine besylate and celecoxib  Consensi

Other Combination Medicines: What You Should Know

  • Caduet is made up of two different kinds of medicines. Amlodipine is a blood pressure medicine. Atorvastatin is a cholesterol-lowering medicine. 
  • Consensi is made up of two different kinds of medicines. Amlodipine is a blood pressure medicine. Celecoxib is a medicine used to treat osteoarthritis.
  • Look for the generic or brand names of amlodipine on the list of calcium channel blockers in this guide. The warnings and side effects for amlodipine will be the same as those listed earlier for calcium channel blockers.
  • For the most complete and up-to-date information about the warnings and side effects for each  medicine of atorvastatin and celecoxib, check http:/www.accessdata.fda.gov/scripts/cder/drugsatfda/.

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have asthma, diabetes, stomach ulcers, heart disease, kidney problems, liver problems, or thyroid problems, talk to your healthcare provider before using this medicine.
  • If you are taking aspirin, blood thinners, corticosteroids, cyclosporine, tacrolimus, antiviral medicines, antibiotics, antifungal medicines, cimetidine, sildenafil, oral contraceptives, or other medicines, talk to your healthcare provider about the risks of using this medicine.

Common Side Effects

  • Swelling of the legs or ankles
  • Muscle or joint pain (mild)
  • Headache
  • Diarrhea or constipation
  • Feeling dizzy
  • Feeling tired or sleepy
  • Gas
  • Rash
  • Nausea
  • Face feels hot or warm

Warning Signs

Seek medical attention if you have any of these signs:

  • Chest pain
  • Allergic reaction (difficulty breathing, hives, rash, or swelling in your whole body)
  • Weakness in part of your body
  • Slurred speech
  • Muscle problems such as weakness, tenderness, or pain that happens without a good reason (e.g., exercise or injury)
  • Bloody vomit or bowel movement
  • Brown or dark-colored urine
  • Skin or eyes look yellow
  • Fast or irregular heartbeat
  • Feel more tired than usual
  • Serious skin rash, itching, or redness
  • Stomach or intestinal pain

Diuretics (sometimes called “water pills”)

Generic Name Brand Name
amiloride and hydrochlorothiazide Midamor
chlorothiazide Diuril
chlorthalidone Generic Medicine Only
eplerenone Inspra
furosemide Lasix
hydrochlorothiazide Microzide
hydrochlorothiazide and spironolactone Aldactazide
hydrochlorothiazide and triamterene Dyazide, Maxzide, and Maxzide-25
indapamide Generic Medicine Only
spironolactone  Aldactone and CaroSpir
torsemide  Demadex
metolazone Zaroxolyn

Diuretics: What You Should Know

Warnings

  • If you are pregnant or nursing, talk to your healthcare provider before using this medicine.
  • If you have kidney or liver problems, talk to your healthcare provider about the risks of using this medicine.
  • If you are taking potassium supplements, lithium, cyclosporine, tacrolimus, nonsteroidal anti-inflammatory drugs, antifungal drugs, antiviral drugs, or other medicines, talk to your healthcare provider about the risks of using this medicine.

Common Side Effects

  • Dizziness
  • Fainting 
  • Frequent urination
  • Headache
  • Upset stomach

Warning Signs

Seek medical attention if you have any of these signs:

  • Sudden vision changes or eye pain
  • Severe rash
  • Problems breathing
  • Irregular heartbeat
  • Feeling thirsty
  • Muscle cramps or weakness
  • Tingling or numbness in hands, arms, legs, or feet
  • Gout

For the most complete and up-to-date information about the risks and side effects for each medicine, check [email protected]


Questions To Ask Your Doctor

  • What is the name of the medicine I am taking? 
  • What are the potential side effects?
  • What other prescription medicines should I avoid while taking my high blood pressure medicine?
  • What foods (such as grapefruit juice), herbs (like St. John’s wort), or over-the-counter medicine should I avoid?
  • When should I take each medicine? How many times per day do I take each medicine?
  • Can I take my medicines if I am pregnant or nursing?

Learn More About Pregnancy Registries

 

 

 


Resources For You

  • FDA Office of Women’s Health Resources
  • National Heart, Lunch and Blood Institute Resources
  • NIH National Library of Medicine MedlinePlus
  • Centers for Disease Control and Prevention

 


This guide should not be used in place of talking to your healthcare provider or reading the label on your medicine bottle.The medicine and risk information in this guide may change and is not all inclusive. High blood pressure medicines and information in this guide are current as of February 2021. 
For the most complete and up-to-date information about the risks and side effects of each medicine, check [email protected]

 

Lopressor, Metoprolol Succinate ER, Metoprolol Tartrate (metoprolol) Uses, Side Effects, Dosage & Interactions

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Metoprolol 100 mg-CAR

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Metoprolol 25 mg-MYL

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Metoprolol 50 mg-WAT

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Metoprolol Succinate 100 mg 498840827

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Metoprolol Succinate 100 mg 683820566

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Metoprolol Succinate ER 25mg 009046322

oval, white, imprinted with M 1

Toprol XL 100 mg

round, white, imprinted with AMS

Toprol XL 200 mg

elliptical, white, imprinted with A MY

Toprol XL 25 mg

oval, white, imprinted with A B

Toprol XL 50 mg

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ursodiol 250 mg 498840412

BP Drug Linked to Severe Diarrheal Illness

LAS VEGAS – A patient’s insightful question led to the identification of almost two dozen cases of severe enteropathy associated with use of a blood pressure medication, investigators reported here.

All of the cases involved use of the angiotensin receptor blocker olmesartan (Benicar), which has since been linked to more than 60 probable cases of severe sprue-like enteropathy, since an initial report of 22 cases, Margot Herman, MD, said at the American College of Gastroenterology meeting.

  • Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  • The angiotensin II receptor blocker (ARB) olmesartan may be associated with a severe form of sprue-like enteropathy.
  • Note that 0lmesartan is one of seven FDA-approved ARBs, but the only one linked to sprue-like enteropathy.

The patient in question, a 59-year-old woman with hypertension, had severe treatment-resistant diarrhea for a year, resulting in substantial weight loss. During a visit with clinicians, the patient asked whether the illness could be caused by her blood pressure medication — olmesartan.

“It seemed unlikely because she had been on olmesartan for more than a year before the onset of symptoms,” said Herman, of the Mayo Clinic in Rochester, Minn. “However, that week another patient asked a similar question.”

Considering the second patient’s question more than a coincidence, investigators reviewed records for an ongoing cohort study of patients with collagenous sprue. They found that 30% of the patients were taking olmesartan.

As Herman and colleagues reported recently, they initially identified 22 patients with severe sprue-like enteropathy associated with use of olmesartan. They had been evaluated at the Mayo Clinic between August 2008 and 2011.

All of the patients had chronic unexplained diarrhea and a median weight loss of 40 pounds, requiring hospitalization in 14 cases and total parenteral nutrition in four. None of the patients responded to a gluten-free diet, and celiac disease was ruled out in all cases.

The patients had a median age of 69.5, and all but one were white. All of the patients received olmesartan for treatment of hypertension, and dosage ranged from 10 to 40 mg/d. All of the patients had used the drug for at least a year before developing symptoms, and some had taken olmesartan for more than 3 years.

Duration of diarrheal illness averaged 19 months, ranging to 53 months. The diarrhea frequently was accompanied by nausea and vomiting, abdominal pain, and bloating.

Intestinal biopsies revealed villous atrophy and evidence of mucosal inflammation in most of the patients. Seven patients had substantial subepithelial collagen deposits.

After discontinuing olmesartan, the 22 patients gained an average of 27 pounds. Follow-up biopsies in 18 patients showed histologic recovery or improvement of the duodenum.

Olmesartan is one of seven FDA-approved ARBs, but the only one linked to sprue-like enteropathy. Herman cited a characteristic of olmesartan that distinguishes it from the other ARBs and possibly provides a clue to the drug’s association with the severe diarrhea and weight loss: prodrug activation in the small intestine.

Since identifying the initial 22 patients with olmesartan-associated sprue-like enteropathy, investigators at Mayo have found at least 22 more cases among patient records. Reports from other centers and from individual patients have raised the total case count to more than 60.

Wondering aloud whether the findings represent “the tip of the iceberg,” a member of the audience asked Herman whether she and her colleagues had examined FDA data on adverse events associated with olmesartan.

“We believe it is the tip of the iceberg, or it appears that it is,” said Herman. “We have looked at FDA data. Unfortunately, because of the significant delay in the onset of this reaction, we haven’t been able to find much evidence.”

In response to a request from MedPage Today, a spokesperson for drug manufacturer Daiichi-Sankyo said by email, “We are aware of the publication which reports on a total of 22 patients taking olmesartan who experienced unexplained sprue-like enteropathy. Improvement of gastrointestinal symptoms was observed once olmesartan was stopped. It’s important to note that the authors acknowledge that ‘this case series lacks all the information necessary to prove causality but rather reflects an association’.”

“Patient safety is important to us. Our olmesartan medoxomil family of products has a well-established safety profile with tens of millions of patient-years of use worldwide since 2002. In pivotal phase III studies, olmesartan medoxomil as monotherapy, and in combination with hydrochlorothiazide or amlodipine, has been shown to be safe, effective and well-tolerated, with an incidence of adverse events similar to placebo.”

  • Charles Bankhead is senior editor for oncology and also covers urology, dermatology, and ophthalmology. He joined MedPage Today in 2007. Follow

Disclosures

Herman and colleagues had no relevant disclosures.

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Memorial Sloan Kettering Cancer Center

This document, provided by Lexicomp ® , contains all the information you need to know about the drug, including the indications, route of administration, side effects and when you should contact your healthcare provider.

Trade names: USA

Kapspargo Sprinkle; Lopressor; Toprol XL

Trade names: Canada

AG-Metoprolol-L; APO-Metoprolol; APO-Metoprolol SR; APO-Metoprolol Type L; DOM-Metoprolol; DOM-Metoprolol-L; JAMP-Metoprolol-L; Lopresor SR; Lopresor [DSC]; Metoprolol-L; PMS-Metoprolol-B; PMS-Metoprolol-L; RIVA-Metoprolol-L; SANDOZ Metoprolol (Type L) [DSC]; Sandoz Metoprolol SR [DSC]; TEVA-Metoprolol

Warning

  • Do not stop taking this drug suddenly.If you stop taking this drug abruptly, your chest pain may worsen and, in some cases, even a heart attack. The risk may be increased with certain types of heart disease. To avoid side effects, this drug should be stopped gradually as directed by your doctor. Call your doctor right away if you experience or worsen chest pain or other heart problems.

What is this drug used for?

  • Used to treat high blood pressure.
  • Used to treat chest pain and chest pressure.
  • Used to treat heart failure (weakened heart).
  • It is used to prevent the development of repeated myocardial infarction and to prolong life.
  • This medicinal product can be used for other indications. Consult your doctor.

What should I tell my doctor BEFORE taking this drug?

  • If you are allergic to this drug, any of its ingredients, other drugs, foods or substances.Tell your doctor about your allergy and how it manifested itself.
  • If you have any of the following health problems: certain types of heart rhythm disturbances called heart block or weak sinus syndrome, heart failure (weakened heart), low blood pressure, poor blood flow to the upper or lower extremities, shock caused by disturbances from the side of the heart, or bradycardia.
  • If you have any of the following health problems: asthma or other breathing problems such as COPD (chronic obstructive pulmonary disease).

This list of drugs and diseases that may be adversely associated with this drug is not exhaustive.

Tell your doctor and pharmacist about all the medicines you take (both prescription and over-the-counter, natural products and vitamins) and your health problems. You need to make sure that this drug is safe for your medical condition and in combination with other drugs you are already taking.Do not start or stop taking any drug or change the dosage without your doctor’s approval.

What do I need to know or do while taking this drug?

  • Tell all healthcare providers that you are taking this drug. These are doctors, nurses, pharmacists and dentists.
  • Avoid driving and other activities that require increased attention until you see how this drug affects you.
  • To reduce the risk of dizziness or loss of consciousness, get up slowly from a lying or sitting position. Use caution when climbing and descending stairs.
  • Measure blood pressure and heart rate as directed by your doctor.
  • Perform blood tests as directed by your doctor. Please consult your doctor.
  • This drug may interfere with some laboratory tests.Tell all healthcare providers and laboratory staff that you are taking this drug.
  • This drug may mask signs of low blood sugar. Consult your doctor.
  • If you have high blood sugar (diabetes), your blood sugar should be checked regularly.
  • If you are taking this drug and have high blood pressure, talk to your doctor before taking any over-the-counter drugs that can raise blood pressure.These drugs include medicines for coughs and colds, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, and some naturally occurring drugs.
  • You may need to refrain from consuming alcoholic beverages with certain medications. Ask your doctor or pharmacist to see if you should refrain from drinking alcoholic beverages with this drug.
  • This drug may increase the severity of these conditions if you have signs of an overactive thyroid gland, such as tachycardia. If you have an overactive thyroid and suddenly stop taking this drug, your condition may worsen and be life threatening. Please consult your doctor.
  • If you have had a very severe allergic reaction, consult your doctor. If you come into contact with the agent that caused the allergy, there is a risk of an even more severe reaction.Talk to your doctor if you are using epinephrine to treat very severe allergic reactions. Epinephrine may not work well while you are taking this drug.
  • Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding. The benefits and risks for you and your child will need to be discussed.

What side effects should I report to my doctor immediately?

WARNING. In rare cases, some people with this drug can have serious and sometimes deadly side effects. Call your healthcare professional or get medical attention right away if you have any of the following signs or symptoms, which may be associated with serious side effects:

  • Signs of an allergic reaction such as rash, hives, itching, reddened and swollen skin with blistering or scaling, possibly associated with fever, wheezing or wheezing, tightness in the chest or throat, difficulty breathing, swallowing or speaking, unusual hoarseness, swelling in the mouth, face, lips, tongue, or throat.
  • Depression.
  • Severe dizziness or fainting.
  • When chest pain occurs or worsens.
  • The appearance or aggravation of cardiac arrhythmias.
  • Bradycardia.
  • Shortness of breath, sudden weight gain, or swelling of the arms or legs.

What are some other side effects of this drug?

Any medicine can have side effects. However, many people have little or no side effects.Call your doctor or get medical help if these or any other side effects bother you or do not go away:

  • Feeling dizzy, tired, or weak.
  • Diarrhea, indigestion or vomiting.

This list of potential side effects is not exhaustive. If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects.

You can report side effects to the National Health Office.

You can report side effects to the FDA at 1-800-332-1088. You can also report side effects at https://www.fda.gov/medwatch.

What is the best way to take this drug?

Use this drug as directed by your healthcare practitioner. Read all the information provided to you. Follow all instructions strictly.

Immediate-release tablets of active ingredient:

  • Take with or immediately after meals.
  • Swallow whole with a full glass of water.
  • Continue taking this drug as directed by your doctor or other healthcare professional, even if you feel well.

Extended release tablets:

  • Take with or immediately after meals.
  • Swallow whole. Do not chew or crumble.
  • You can break a tablet in half. Do not chew or grind.
  • Continue taking this drug as directed by your doctor or other healthcare professional, even if you feel well.

Sustained-release capsules:

  • Take this medication with or without food.
  • Swallow whole. Do not chew or crumble.
  • If you cannot swallow this drug whole, pour the contents into applesauce, pudding, yogurt, or other soft foods.Then swallow the mixture without chewing within 60 minutes after mixing. Do not store for future use.
  • Continue taking this drug as directed by your doctor or other healthcare professional, even if you feel well.
  • Patients with feeding tubes may use this medication. Apply as directed. Flush the feeding tube after using this drug.

Injection:

  • For intravenous injection.

What should I do if a dose of a drug is missed?

All oral preparations:

  • Skip the forgotten dose and return to your normal schedule.
  • Do not take 2 doses at the same time or an additional dose.

Injection:

  • Call your doctor for further instructions.

How do I store and / or discard this drug?

All oral preparations:

  • Store at room temperature in a dry place.Do not store in the bathroom.
  • Protect from heat.

Injection:

  • If you need to store this drug at home, ask your doctor, nurse, or pharmacist for information about how it is stored.

All forms of issue:

  • Store all medicines in a safe place. Keep all medicines out of the reach of children and pets.
  • Dispose of unused or expired drugs.Do not empty into toilet or drain unless directed to do so. If you have any questions about the disposal of your medicinal products, consult your pharmacist. Your area may have drug recycling programs.

General information on medicinal products

  • If your health does not improve or even worsens, see your doctor.
  • You should not give your medicine to anyone and take other people’s medicines.
  • Some medicines may have different patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • Some medicines may have different patient information sheets. Check with your pharmacist. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • If you think there has been an overdose of a drug, call a Poison Control Center immediately or seek medical attention. Be prepared to tell or show which drug you took, how much and when it happened.

Use of information by consumer and limitation of liability

This information should not be used to make decisions about taking this or any other drug. Only the attending physician has the necessary knowledge and experience to make decisions about which drugs are appropriate for a particular patient.This information does not guarantee that the drug is safe, effective, or approved for the treatment of any disease or specific patient. Here are only brief general information about this drug. It does NOT contain all available information on the possible use of the drug with instructions for use, warnings, precautions, information about interactions, side effects and risks that may be associated with this drug. This information should not be construed as a treatment guide and does not replace information provided to you by your healthcare professional.For complete information on the possible risks and benefits of taking this drug, consult your doctor. Use of this information is governed by the Lexicomp End User License Agreement available at https://www.wolterskluwer.com/en/solutions/lexicomp/about/eula.

Copyright

© UpToDate, Inc. and its affiliates and / or licensors, 2021. All rights reserved.

Metoprolol and Hydrochlorothiazide | Memorial Sloan Kettering Cancer Center

This document, provided by Lexicomp ® , contains all the information you need to know about the drug, including the indications, route of administration, side effects and when you should contact your healthcare provider.

Trade names: USA

Dutoprol; Lopressor HCT [DSC]

Warning

  • Do not stop taking this drug suddenly. If you stop taking this drug abruptly, your chest pain may worsen and, in some cases, even a heart attack. The risk may be increased with certain types of heart disease. To avoid side effects, this drug should be stopped gradually as directed by your doctor.Call your doctor right away if you experience or worsen chest pain or other heart problems.

What is this drug used for?

  • Used to treat high blood pressure.

What should I tell my doctor BEFORE taking this drug?

  • If you are allergic to this drug, any of its ingredients, other drugs, foods or substances. Tell your doctor about your allergy and how it manifested itself.
  • If you are allergic to sulfonamides.
  • If you have any of the following health problems: certain types of heart rhythm disturbances called heart block or weak sinus syndrome, heart failure (weakened heart), low blood pressure, poor blood flow to the upper or lower extremities, shock caused by disturbances from the side of the heart, or bradycardia.
  • If you have any of the following health problems: asthma or other breathing problems such as COPD (chronic obstructive pulmonary disease).
  • Inability to urinate.
  • When taking dofetilide.

This list of drugs and diseases that may be adversely associated with this drug is not exhaustive.

Tell your doctor and pharmacist about all the medicines you take (both prescription and over-the-counter, natural products and vitamins) and your health problems. You need to make sure that this drug is safe for your medical condition and in combination with other drugs you are already taking.Do not start or stop taking any drug or change the dosage without your doctor’s approval.

What do I need to know or do while taking this drug?

  • Tell all healthcare providers that you are taking this drug. These are doctors, nurses, pharmacists and dentists.
  • Avoid driving and other activities that require increased attention until you see how this drug affects you.
  • To reduce the risk of dizziness or loss of consciousness, get up slowly from a lying or sitting position. Use caution when climbing and descending stairs.
  • Measure blood pressure and heart rate as directed by your doctor.
  • Perform blood tests as directed by your doctor. Please consult your doctor.
  • This drug may interfere with some laboratory tests.Tell all healthcare providers and laboratory staff that you are taking this drug.
  • Consult your doctor before using alcohol, marijuana or other forms of cannabis, or prescription and over-the-counter drugs that may slow you down.
  • This drug may mask signs of low blood sugar. Consult your doctor.
  • If you have high blood sugar (diabetes), your blood sugar should be checked regularly.
  • Caution should be exercised in hot weather and during vigorous activity. Drink plenty of fluids to stay hydrated.
  • Tell your doctor if you experience excessive sweating, fluid loss, vomiting, or loose stools. This can lead to a drop in blood pressure.
  • Watch for gout attacks.
  • If you have lupus, this drug can make lupus active or make it worse. If any new symptom develops or symptoms worsen, contact your healthcare professional immediately.
  • Talk to your doctor before taking any over-the-counter drug that can increase blood pressure. These drugs include medicines for coughs and colds, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, and some naturally occurring drugs.
  • This drug may increase the severity of these conditions if you have signs of an overactive thyroid gland, such as tachycardia.If you have an overactive thyroid and suddenly stop taking this drug, your condition may worsen and be life threatening. Please consult your doctor.
  • If you have had a very severe allergic reaction, consult your doctor. If you come into contact with the agent that caused the allergy, there is a risk of an even more severe reaction. Talk to your doctor if you are using epinephrine to treat very severe allergic reactions.Epinephrine may not work well while you are taking this drug.
  • If you are 65 years of age or older, use this drug with caution. You may have more side effects.
  • Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding. The benefits and risks for you and your child will need to be discussed.

What side effects should I report to my doctor immediately?

WARNING. In rare cases, some people with this drug can have serious and sometimes deadly side effects. Call your healthcare professional or get medical attention right away if you have any of the following signs or symptoms, which may be associated with serious side effects:

  • Signs of an allergic reaction such as rash, hives, itching, reddened and swollen skin with blistering or scaling, possibly associated with fever, wheezing or wheezing, tightness in the chest or throat, difficulty breathing, swallowing or speaking, unusual hoarseness, swelling in the mouth, face, lips, tongue, or throat.
  • Signs of high blood sugar, such as confusion, drowsiness, increased thirst and hunger, increased urination, facial flushing, rapid breathing, and fruity breath.
  • Signs of imbalance in fluid and electrolytes, incl. sudden changes in mood, confusion of thought, muscle pain or weakness, a feeling of disturbed heartbeat, severe dizziness or loss of consciousness, rapid heartbeat, intense thirst, seizures, feeling very tired or weak, lack of appetite, inability to urinate or change in the amount of urine excreted, dryness in mouth, dry eyes, severe stomach upset, or vomiting.
  • Signs of kidney problems, including lack of urination, change in urine volume, blood in the urine, or rapid weight gain.
  • When chest pain occurs or worsens.
  • Bradycardia.
  • Depression.
  • Confusion of consciousness.
  • Violation or loss of memory.
  • Shortness of breath, sudden weight gain, or swelling of the arms or legs.
  • This drug may cause certain eye problems. Left untreated, these problems can lead to long-term vision loss.In cases where such eye problems have occurred, symptoms such as blurred vision or pain in the eyes usually appeared in the period from the first hours to the first weeks after starting the drug. Call your doctor immediately if you experience these symptoms.
  • In rare cases, the use of hydrochlorothiazide has been associated with the development of certain types of skin cancer. Protect your skin from the sun and have a skin exam as directed by your healthcare professional. If the color or size of birthmarks or any new or changing skin tumors or growths changes, contact your doctor immediately.

What are some other side effects of this drug?

Any medicine can have side effects. However, many people have little or no side effects. Call your doctor or get medical help if these or any other side effects bother you or do not go away:

  • Feeling dizzy, sleepy, tired, or weak.
  • Headache.
  • Diarrhea.
  • Flu-like symptoms.

This list of potential side effects is not exhaustive. If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects.

You can report side effects to the National Health Office.

You can report side effects to the FDA at 1-800-332-1088. You can also report side effects at https: // www.fda.gov/medwatch.

What is the best way to take this drug?

Use this drug as directed by your healthcare practitioner. Read all the information provided to you. Follow all instructions strictly.

  • Certain other brands of this drug must be taken with food. Some brands of the drug can be taken with or without food. Ask your pharmacist if you need to take your prescribed brand of drug with food.
  • Continue taking this drug as directed by your doctor or other healthcare professional, even if you feel well.
  • This drug may cause frequent urination. This can lead to sleep disturbances, so try not to take the drug shortly before going to bed.
  • Drink plenty of decaffeinated fluids, unless your doctor tells you to drink less fluids.
  • If you are taking cholestyramine or colestipol, talk with your pharmacist about how to take them with this drug.

What should I do if a dose of a drug is missed?

  • Skip the forgotten dose and return to your normal schedule.
  • Do not take 2 doses at the same time or an additional dose.

How do I store and / or discard this drug?

  • Store at room temperature, protected from light. Store in a dry place. Do not store in the bathroom.
  • Store all medicines in a safe place.Keep all medicines out of the reach of children and pets.
  • Dispose of unused or expired drugs. Do not empty into toilet or drain unless directed to do so. If you have any questions about the disposal of your medicinal products, consult your pharmacist. Your area may have drug recycling programs.

General information on medicinal products

  • If your health does not improve or even worsens, see your doctor.
  • You should not give your medicine to anyone and take other people’s medicines.
  • Some medicines may have different patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • Some medicines may have different patient information sheets. Check with your pharmacist. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • If you think there has been an overdose of a drug, call a Poison Control Center immediately or seek medical attention. Be prepared to tell or show which drug you took, how much and when it happened.

Use of information by consumer and limitation of liability

This information should not be used to make decisions about taking this or any other drug. Only the attending physician has the necessary knowledge and experience to make decisions about which drugs are appropriate for a particular patient.This information does not guarantee that the drug is safe, effective, or approved for the treatment of any disease or specific patient. Here are only brief general information about this drug. It does NOT contain all available information on the possible use of the drug with instructions for use, warnings, precautions, information about interactions, side effects and risks that may be associated with this drug. This information should not be construed as a treatment guide and does not replace information provided to you by your healthcare professional.For complete information on the possible risks and benefits of taking this drug, consult your doctor. Use of this information is governed by the Lexicomp End User License Agreement available at https://www.wolterskluwer.com/en/solutions/lexicomp/about/eula.

Copyright

© UpToDate, Inc. and its affiliates and / or licensors, 2021. All rights reserved.

Metoprolol instructions for use: indications, contraindications, side effects – description of Metoprolol tab.25 mg: 10, 20, 30, 40, 50 or 60 pcs. (27338)

When used simultaneously with antihypertensive drugs, diuretics, antiarrhythmic drugs, nitrates, there is a risk of severe arterial hypotension, bradycardia, AV blockade.

When used simultaneously with barbiturates, the metabolism of metoprolol is accelerated, which leads to a decrease in its effectiveness.

With simultaneous use with hypoglycemic agents, it is possible to enhance the effect of hypoglycemic agents.

With simultaneous use with NSAIDs, it is possible to reduce the hypotensive effect of metoprolol.

With simultaneous use with opioid analgesics, the cardiodepressant effect is mutually enhanced.

With simultaneous use with peripheral muscle relaxants, neuromuscular blockade may increase.

With simultaneous use with agents for inhalation anesthesia, the risk of inhibition of myocardial function and the development of arterial hypotension increases.

With simultaneous use with oral contraceptives, hydralazine, ranitidine, cimetidine, the concentration of metoprolol in blood plasma increases.

With simultaneous use with amiodarone, arterial hypotension, bradycardia, ventricular fibrillation, asystole are possible.

With simultaneous use with verapamil, C max in blood plasma and AUC of metoprolol increase. The minute and stroke volume of the heart, pulse rate, arterial hypotension decrease.Perhaps the development of heart failure, dyspnea and sinus blockade.

With intravenous administration of verapamil while taking metoprolol, there is a threat of cardiac arrest.

With simultaneous use, it is possible to increase the bradycardia caused by digitalis glycosides.

When used simultaneously with dextropropoxyphene, the bioavailability of metoprolol increases.

With simultaneous use with diazepam, a decrease in clearance and an increase in AUC of diazepam is possible, which can lead to an increase in its effects and a decrease in the speed of psychomotor reactions.

With simultaneous use with diltiazem, the concentration of metoprolol in the blood plasma increases due to the inhibition of its metabolism under the influence of diltiazem. The effect on the activity of the heart is additively inhibited due to the slowing down of the impulse conduction through the AV node caused by diltiazem. There is a risk of developing severe bradycardia, a significant decrease in stroke and minute volume.

With simultaneous use with lidocaine, a violation of the excretion of lidocaine is possible.

With simultaneous use with mibefradil in patients with low activity of the isoenzyme CYP2D6, it is possible to increase the concentration of metoprolol in the blood plasma and increase the risk of toxic effects.

With simultaneous use with norepinephrine, epinephrine, other adreno- and sympathomimetics (including in the form of eye drops or as part of antitussives), a slight increase in blood pressure is possible.

With simultaneous use with propafenone, the concentration of metoprolol in the blood plasma increases and a toxic effect develops.It is believed that propafenone inhibits the metabolism of metoprolol in the liver, decreasing its clearance and increasing serum concentrations.

With simultaneous use with reserpine, guanfacine, methyldopa, clonidine, severe bradycardia may develop.

With simultaneous use with rifampicin, the concentration of metoprolol in blood plasma decreases.

Metoprolol may cause a slight decrease in theophylline clearance in smokers.

Fluoxetine inhibits the isoenzyme CYP2D6, this leads to inhibition of the metabolism of metoprolol and its cumulation, which can enhance the cardiodepressant effect and cause bradycardia.A case of lethargy development is described.

Fluoxetine and mainly its metabolites are characterized by a prolonged T 1/2 , so the likelihood of drug interaction persists even several days after discontinuation of fluoxetine.

There are reports of a decrease in the clearance of metoprolol from the body when used simultaneously with ciprofloxacin.

With simultaneous use with ergotamine may increase peripheral circulatory disorders.

With simultaneous use with estrogens, the antihypertensive effect of metoprolol decreases.

With the simultaneous use of metoprolol increases the concentration of ethanol in the blood and lengthens its excretion.

METOPROLOL 50mg 50 pcs. tablets

Composition and release form Metoprolol 50mg 50 pcs. tablets

1 tablet contains:

  • Active ingredient: metoprolol 50mg.
  • Auxiliary substances: colloidal silicon dioxide, potato starch, crospovidone, lactose monohydrate, magnesium stearate, povidone.

Tablets 50 pcs.

Description of the dosage form

Tablets of a flat-cylindrical shape, white with a grayish or white with a yellowish shade, with a bevel. “Marbling” is allowed.

Characteristic

Has hypotensive, antianginal and antiarrhythmic effects.

Method of administration and dosage

For oral administration, the average dose is 100 mg / in 1-2 doses. If necessary, the daily dose is gradually increased to 200 mg. Maximum doses: for oral administration, the daily dose is 400 mg.

Pharmacodynamics

Cardioselective beta1-blocker without intrinsic sympathomimetic activity.Reduces the automatism of the sinus node, reduces heart rate, slows down AV conduction, reduces myocardial contractility and excitability, decreases cardiac output, and reduces myocardial oxygen demand. Suppresses the stimulating effect of catecholamines on the heart during physical and psycho-emotional stress.

Causes a hypotensive effect, which stabilizes by the end of the 2nd week of course use. With exertional angina, metoprolol reduces the frequency and severity of attacks. Normalizes heart rate with supraventricular tachycardia and atrial fibrillation.In case of myocardial infarction, it helps to limit the zone of ischemia of the heart muscle and reduces the risk of developing fatal arrhythmias, reduces the possibility of recurrence of myocardial infarction. When used in moderate therapeutic doses, it has a less pronounced effect on the smooth muscles of the bronchi and peripheral arteries than non-selective beta-blockers.

Pharmacokinetics

After oral administration, metoprolol is rapidly and almost completely absorbed from the gastrointestinal tract, the Cmax of the active substance in the blood plasma is reached after 1-2 hours.It is extensively metabolized in the liver with the formation of inactive metabolites.

T1 / 2 of metoprolol from plasma is 3-4 hours and does not change during the course of treatment. More than 95% of the dose taken is excreted by the kidneys, of which only 3% is unchanged.

Indications for use Metoprolol 50mg 50 pcs. tablets

Arterial hypertension, prevention of angina attacks, cardiac arrhythmias (supraventricular tachycardia, extrasystole), secondary prevention after myocardial infarction, hyperkinetic cardiac syndrome (incl.h. with hyperthyroidism, NCD). Prevention of migraine attacks.

Contraindications

AV block II and III degrees, sinoatrial blockade, bradycardia (heart rate less than 50 beats / min), CVS, arterial hypotension, chronic heart failure stage IIB-III, acute heart failure, cardiogenic shock, metabolic acidosis, severe peripheral circulatory disorders, hypersensitivity to metoprolol.

Effect on the body

Has hypotensive, antianginal and antiarrhythmic effects.

Side effects Metoprolol 50mg 50 pcs. tablets

From the side of the cardiovascular system: bradycardia, arterial hypotension, AV-conduction disturbances, symptoms of heart failure are possible.

From the digestive system: at the beginning of therapy, dry mouth, nausea, vomiting, diarrhea, constipation are possible; in some cases – liver dysfunction.

From the side of the central nervous system and peripheral nervous system: at the beginning of therapy, weakness, fatigue, dizziness, headache, muscle cramps, feeling of cold and paresthesia in the extremities are possible; possible decrease in the secretion of lacrimal fluid, conjunctivitis, rhinitis, depression, sleep disturbances, nightmares.

From the hematopoietic system: in some cases – thrombocytopenia.

From the endocrine system: hypoglycemic conditions in patients with diabetes mellitus.

From the endocrine system: hypoglycemic conditions in patients with diabetes mellitus.

Allergic reactions: skin rash, itching.

Drug interactions

When used simultaneously with antihypertensive drugs, diuretics, antiarrhythmic drugs, nitrates, there is a risk of severe arterial hypotension, bradycardia, AV blockade.

When used simultaneously with barbiturates, the metabolism of metoprolol is accelerated, which leads to a decrease in its effectiveness.

With simultaneous use with NSAIDs, it is possible to reduce the hypotensive effect of metoprolol.

With simultaneous use with opioid analgesics, the cardiodepressant effect is mutually enhanced.