metoprolol/hydrochlorothiazide (Rx)

Brand and Other Names:Lopressor HCT, Dutoprol
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

metoprolol/hydrochlorothiazide

tablet (Lopressor HCT)

  • 50mg/25mg
  • 100mg/25mg
  • 100mg/50mg

tablet (Dutoprol)

  • 25mg/12.5mg
  • 50mg/12.5mg
  • 100mg/12.5mg

Hypertension

Not indicated for initial therapy; if fixed combination represents dose titrated to patient’s needs, therapy with combination may be more convenient than with separate components

Lopressor HCT: metoprolol tartrate 50-100 mg and hydrochlorothiazide 25-50 mg PO daily in single or divided doses

Dutoprol: metoprolol succinate 25-100mg and hydrochlorothiazide 12.5 mg PO qDay as a single dose

When necessary, another antihypertensive agent may be added, beginning with 50% of usual recommended starting dose to avoid excessive fall in blood pressure

To minimize dose-independent side effects, begin combination therapy only after patient fails to achieve desired effect with monotherapy

Renal Impairment

Use caution in dosing/titrating patients with renal dysfunction

Cumulative effects of thiazides may develop with impaired renal function

Other Information

Combination may be substituted for titrated individual components

Withdraw gradually over a period of about 2 weeks

Geriatric: Start at low end of dosing range and titrate slowly

<18 years: Safety/efficacy not established

Hypertension

Not indicated for initial therapy; if fixed combination represents dose titrated to patient’s needs, therapy with combination may be more convenient than with separate components

Lopressor HCT: metoprolol tartrate 50-100 mg and hydrochlorothiazide 25-50 mg PO daily in single or divided doses

Dutoprol: metoprolol succinate 25-100mg amd hydrochlorothiazide 12.5 mg PO qDay as a single dose

When necessary, another antihypertensive agent may be added, beginning with 50% of usual recommended starting dose to avoid excessive fall in blood pressure

To minimize dose-independent side effects, begin combination therapy only after patient fails to achieve desired effect with monotherapy

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Interactions

Interaction Checker

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              • acebutolol

                acebutolol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • artemether/lumefantrine

                artemether/lumefantrine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.

              • atenolol

                atenolol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • betaxolol

                betaxolol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • bisoprolol

                bisoprolol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • carvedilol

                carvedilol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • celiprolol

                celiprolol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • chlorpromazine

                metoprolol, chlorpromazine. Either increases levels of the other by decreasing metabolism. Contraindicated. Not all beta blockers share this interaction (e.g., atenolol, nadolol, sotalol do not interact).

              • clonidine

                clonidine, metoprolol. Either increases toxicity of the other by unspecified interaction mechanism. Avoid or Use Alternate Drug. Can increase risk of bradycardia.

              • dacomitinib

                dacomitinib will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug. Avoid use with CYP2D6 substrates where minimal increases in concentration of the CYP2D6 substrate may lead to serious or life-threatening toxicities.

              • digoxin

                digoxin increases toxicity of metoprolol by unspecified interaction mechanism. Avoid or Use Alternate Drug. Can increase risk of bradycardia.

              • diltiazem

                diltiazem, metoprolol. Either increases toxicity of the other by unspecified interaction mechanism. Avoid or Use Alternate Drug. Can increase risk of bradycardia.

              • elvitegravir/cobicistat/emtricitabine/tenofovir DF

                elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug. Cobicistat is a CYP2D6 inhibitor; caution with CYP2D6 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

              • esmolol

                esmolol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • fexinidazole

                fexinidazole, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration of fexinidazole with drugs known to induce bradycardia. .

              • fluoxetine

                fluoxetine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.

              • givosiran

                givosiran will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP2D6 substrates with givosiran. If unavoidable, decrease the CYP2D6 substrate dosage in accordance with approved product labeling.

              • labetalol

                labetalol and metoprolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • lofexidine

                lofexidine, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration with other drugs that decrease pulse or blood pressure to mitigate risk of excessive bradycardia and hypotension.

              • lumefantrine

                lumefantrine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.

              • nadolol

                metoprolol and nadolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • nebivolol

                metoprolol and nebivolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • paroxetine

                paroxetine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.

              • penbutolol

                metoprolol and penbutolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • pindolol

                metoprolol and pindolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • propranolol

                metoprolol and propranolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • quinidine

                quinidine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug. If concurrent therapy required, monitor cardiac function carefully (blood pressure, heart rate). A dosage adjustment may be required for both drugs.

              • rivastigmine

                metoprolol increases toxicity of rivastigmine by pharmacodynamic synergism. Avoid or Use Alternate Drug. Additive bradycardia effect may result in syncope.

              • sotalol

                metoprolol and sotalol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • thioridazine

                metoprolol, thioridazine. Either increases levels of the other by decreasing metabolism. Contraindicated. Not all beta blockers share this interaction (e.g., atenolol, nadolol, sotalol do not interact).

              • thiothixene

                metoprolol, thiothixene. Either increases levels of the other by decreasing metabolism. Contraindicated. Not all beta blockers share this interaction (e.g., atenolol, nadolol, sotalol do not interact).

              • timolol

                metoprolol and timolol both increase anti-hypertensive channel blocking. Avoid or Use Alternate Drug.

              • verapamil

                verapamil, metoprolol. Either increases toxicity of the other by unspecified interaction mechanism. Avoid or Use Alternate Drug. Can increase risk of bradycardia.

              Monitor Closely (202)

              • abiraterone

                abiraterone increases levels of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Avoid coadministration of abiraterone with substrates of CYP2D6. If alternative therapy cannot be used, exercise caution and consider a dose reduction of the CYP2D6 substrate.

              • acebutolol

                acebutolol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • aceclofenac

                metoprolol and aceclofenac both increase serum potassium. Use Caution/Monitor.

                aceclofenac decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • acemetacin

                metoprolol and acemetacin both increase serum potassium. Use Caution/Monitor.

                acemetacin decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • albuterol

                metoprolol increases and albuterol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of albuterol by pharmacodynamic antagonism. Use Caution/Monitor.

              • aldesleukin

                aldesleukin increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • alfuzosin

                alfuzosin and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • aluminum hydroxide

                aluminum hydroxide decreases levels of metoprolol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. Separate by 2 hours.

              • amifostine

                amifostine, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration with blood pressure lowering agents may increase the risk and severity of hypotension associated with amifostine. When amifostine is used at chemotherapeutic doses, withhold blood pressure lowering medications for 24 hr prior to amifostine; if blood pressure lowering medication cannot be withheld, do not administer amifostine.

              • amiloride

                metoprolol and amiloride both increase serum potassium. Modify Therapy/Monitor Closely.

              • amiodarone

                amiodarone will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Monitor cardiac function carefully and observe for signs of bradycardia or heart block when amiodarone and a beta adrenergic blocker are coadministered. Amiodarone should be used with caution in patients receiving a beta adrenergic blocker, particularly if there is suspicion of underlying dysfunction of the sinus node, such as bradycardia or sick sinus syndrome, or if there is partial AV block.

                amiodarone, metoprolol. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of cardiotoxicity with bradycardia.

              • amobarbital

                amobarbital decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of amobarbital. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • arformoterol

                metoprolol increases and arformoterol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of arformoterol by pharmacodynamic antagonism. Use Caution/Monitor.

              • asenapine

                asenapine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

                asenapine and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • aspirin

                metoprolol and aspirin both increase serum potassium. Use Caution/Monitor.

                aspirin decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • aspirin rectal

                metoprolol and aspirin rectal both increase serum potassium. Use Caution/Monitor.

                aspirin rectal decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • aspirin/citric acid/sodium bicarbonate

                aspirin/citric acid/sodium bicarbonate decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

                metoprolol and aspirin/citric acid/sodium bicarbonate both increase serum potassium. Use Caution/Monitor.

              • atazanavir

                atazanavir increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of hypotension, bradycardia, AV block, and prolonged PR interval. Consider lowering beta blocker dose.

              • atenolol

                atenolol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • avanafil

                avanafil increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • bendroflumethiazide

                metoprolol increases and bendroflumethiazide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • betaxolol

                betaxolol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • bismuth subsalicylate

                bismuth subsalicylate, metoprolol. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Blockage of renal prostaglandin synthesis; may cause severe hypertension.

              • bisoprolol

                bisoprolol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • bretylium

                metoprolol, bretylium. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Each drug may cause hypotension.

              • bumetanide

                metoprolol increases and bumetanide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • bupropion

                bupropion will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • butabarbital

                butabarbital decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of butabarbital. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • butalbital

                butalbital decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of butalbital. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • calcium acetate

                calcium acetate decreases effects of metoprolol by unspecified interaction mechanism. Use Caution/Monitor.

              • calcium carbonate

                calcium carbonate decreases effects of metoprolol by unspecified interaction mechanism. Use Caution/Monitor.

                calcium carbonate decreases levels of metoprolol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. Separate by 2 hours.

              • calcium chloride

                calcium chloride decreases effects of metoprolol by unspecified interaction mechanism. Use Caution/Monitor.

              • calcium citrate

                calcium citrate decreases effects of metoprolol by unspecified interaction mechanism. Use Caution/Monitor.

              • calcium gluconate

                calcium gluconate decreases effects of metoprolol by unspecified interaction mechanism. Use Caution/Monitor.

              • candesartan

                candesartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, candesartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • carbenoxolone

                metoprolol increases and carbenoxolone decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • carbidopa

                carbidopa increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Therapy with carbidopa, given with or without levodopa or carbidopa-levodopa combination products, is started, dosage adjustment of the antihypertensive drug may be required.

              • carvedilol

                carvedilol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • celecoxib

                celecoxib will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

                metoprolol and celecoxib both increase serum potassium. Use Caution/Monitor.

                celecoxib decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • celiprolol

                celiprolol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • chloroquine

                chloroquine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • chlorothiazide

                metoprolol increases and chlorothiazide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • chlorthalidone

                metoprolol increases and chlorthalidone decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • choline magnesium trisalicylate

                metoprolol and choline magnesium trisalicylate both increase serum potassium. Use Caution/Monitor.

                choline magnesium trisalicylate decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • cimetidine

                cimetidine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • citalopram

                citalopram increases levels of metoprolol by decreasing metabolism. Use Caution/Monitor. Increased metoprolol plasma levels have been associated with decreased cardioselectivity.

              • clevidipine

                metoprolol and clevidipine both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • clonidine

                metoprolol, clonidine. Mechanism: pharmacodynamic synergism. Modify Therapy/Monitor Closely. Selective beta blocker administration during withdrawal from centrally acting alpha agonists may result in rebound hypertension.

                clonidine, metoprolol. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Additive sympatholytic action may worsen sinus node dysfunction and atrioventricular (AV) block.

              • cobicistat

                cobicistat will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • cyclopenthiazide

                metoprolol increases and cyclopenthiazide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • darifenacin

                darifenacin will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • darunavir

                darunavir will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • dasiglucagon

                metoprolol decreases effects of dasiglucagon by unknown mechanism. Use Caution/Monitor. Dasiglucagon may stimulate catecholamine release; whereas beta blockers may inhibit catecholamines released in response to dasiglucagon. Coadministration may also transiently increase pulse and BP.

              • desflurane

                desflurane, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • desvenlafaxine

                desvenlafaxine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Desvenlafaxine inhibits CYP2D6; with higher desvenlafaxine doses (ie, 400 mg) decrease the CYP2D6 substrate dose by up to 50%; no dosage adjustment needed with desvenlafaxine doses <100 mg

              • diclofenac

                metoprolol and diclofenac both increase serum potassium. Use Caution/Monitor.

                diclofenac decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • diflunisal

                metoprolol and diflunisal both increase serum potassium. Use Caution/Monitor.

                diflunisal decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • digoxin

                metoprolol and digoxin both increase serum potassium. Use Caution/Monitor.

                metoprolol increases effects of digoxin by pharmacodynamic synergism. Use Caution/Monitor. Enhanced bradycardia.

              • diltiazem

                metoprolol and diltiazem both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • diphenhydramine

                diphenhydramine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • dobutamine

                metoprolol increases and dobutamine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of dobutamine by pharmacodynamic antagonism. Use Caution/Monitor.

              • dopexamine

                metoprolol increases and dopexamine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of dopexamine by pharmacodynamic antagonism. Use Caution/Monitor.

              • doxazosin

                doxazosin and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • dronedarone

                dronedarone will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • drospirenone

                metoprolol and drospirenone both increase serum potassium. Modify Therapy/Monitor Closely.

              • duloxetine

                duloxetine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • eliglustat

                eliglustat increases levels of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the concomitant drug and titrate to clinical effect.

              • ephedrine

                metoprolol increases and ephedrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of ephedrine by pharmacodynamic antagonism. Use Caution/Monitor.

              • epinephrine

                metoprolol increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of epinephrine by pharmacodynamic antagonism. Use Caution/Monitor.

              • epinephrine racemic

                metoprolol increases and epinephrine racemic decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of epinephrine racemic by pharmacodynamic antagonism. Use Caution/Monitor.

              • eprosartan

                eprosartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, eprosartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • esmolol

                esmolol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • ethacrynic acid

                metoprolol increases and ethacrynic acid decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • ether

                metoprolol, ether. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Both beta blockers and ether depress the myocardium; consider lowering beta blocker dose if ether used for anesthesia.

              • etodolac

                metoprolol and etodolac both increase serum potassium. Use Caution/Monitor.

                etodolac decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • etomidate

                etomidate, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • fedratinib

                fedratinib will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Adjust dose of drugs that are CYP2D6 substrates as necessary.

              • felodipine

                metoprolol and felodipine both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • fenbufen

                metoprolol and fenbufen both increase serum potassium. Use Caution/Monitor.

              • fenoprofen

                metoprolol and fenoprofen both increase serum potassium. Use Caution/Monitor.

                fenoprofen decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • fingolimod

                metoprolol increases effects of fingolimod by pharmacodynamic synergism. Use Caution/Monitor. Both medications decrease heart rate. Monitor patients on concomitant therapy, particularly in the first 6 hours after fingolimod is initiated or after a treatment interruption of at least two weeks, for bradycardia and atrioventricular block. To identify underlying risk factors of bradycardia and AV block, obtain a new or recent ECG in patients using beta-blockers prior to starting fingolimod.

              • flurbiprofen

                metoprolol and flurbiprofen both increase serum potassium. Use Caution/Monitor.

                flurbiprofen decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • formoterol

                metoprolol increases and formoterol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of formoterol by pharmacodynamic antagonism. Use Caution/Monitor.

              • furosemide

                metoprolol increases and furosemide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • gentamicin

                metoprolol increases and gentamicin decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • glucagon

                glucagon decreases toxicity of metoprolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • glucagon intranasal

                glucagon intranasal decreases toxicity of metoprolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • haloperidol

                haloperidol will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • hydralazine

                hydralazine increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.

              • hydrochlorothiazide

                metoprolol increases and hydrochlorothiazide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                hydrochlorothiazide, metoprolol. Either increases toxicity of the other by Other (see comment). Modify Therapy/Monitor Closely. Comment: May cause idiosyncratic reaction, resulting in acute transient myopia and acute angle-closure glaucoma, which can lead to permanent vision loss.

              • ibuprofen

                metoprolol and ibuprofen both increase serum potassium. Use Caution/Monitor.

                ibuprofen decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • ibuprofen IV

                ibuprofen IV decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

                metoprolol and ibuprofen IV both increase serum potassium. Use Caution/Monitor.

              • imatinib

                imatinib will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • indacaterol, inhaled

                indacaterol, inhaled, metoprolol. Other (see comment). Use Caution/Monitor. Comment: Beta-blockers and indacaterol may interfere with the effect of each other when administered concurrently. Beta-blockers may produce severe bronchospasm in COPD patients. Therefore, patients with COPD should not normally be treated with beta-blockers. However, under certain circumstances, e.g. as prophylaxis after myocardial infarction, there may be no acceptable alternatives to the use of beta-blockers in patients with COPD. In this setting, cardioselective beta-blockers could be considered, although they should be administered with caution.

              • indapamide

                metoprolol increases and indapamide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • indomethacin

                metoprolol and indomethacin both increase serum potassium. Use Caution/Monitor.

                indomethacin decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • insulin degludec

                metoprolol, insulin degludec. Other (see comment). Modify Therapy/Monitor Closely. Comment: Beta-blockers may either increase or decrease the blood glucose lowering effect of insulin; beta-blockers can prolong hypoglycemia (interference with glycogenolysis) or cause hyperglycemia (insulin secretion inhibited).

              • insulin degludec/insulin aspart

                metoprolol, insulin degludec/insulin aspart. Other (see comment). Modify Therapy/Monitor Closely. Comment: Beta-blockers may either increase or decrease the blood glucose lowering effect of insulin; beta-blockers can prolong hypoglycemia (interference with glycogenolysis) or cause hyperglycemia (insulin secretion inhibited).

              • insulin inhaled

                metoprolol, insulin inhaled. Other (see comment). Modify Therapy/Monitor Closely. Comment: Beta-blockers may either increase or decrease the blood glucose lowering effect of insulin; beta-blockers can prolong hypoglycemia (interference with glycogenolysis) or cause hyperglycemia (insulin secretion inhibited).

              • irbesartan

                irbesartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, irbesartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • isoproterenol

                metoprolol increases and isoproterenol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of isoproterenol by pharmacodynamic antagonism. Use Caution/Monitor.

              • isradipine

                metoprolol and isradipine both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • ivabradine

                ivabradine, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Most patients receiving ivabradine will also be treated with a beta-blocker. The risk of bradycardia increases with coadministration of drugs that slow heart rate (eg, digoxin, amiodarone, beta-blockers). Monitor heart rate in patients taking ivabradine with other negative chronotropes.

              • ketamine

                ketamine, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • ketoprofen

                metoprolol and ketoprofen both increase serum potassium. Use Caution/Monitor.

                ketoprofen decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • ketorolac

                metoprolol and ketorolac both increase serum potassium. Use Caution/Monitor.

                ketorolac decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • ketorolac intranasal

                metoprolol and ketorolac intranasal both increase serum potassium. Use Caution/Monitor.

                ketorolac intranasal decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • labetalol

                labetalol and metoprolol both increase serum potassium. Use Caution/Monitor.

              • levalbuterol

                metoprolol increases and levalbuterol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of levalbuterol by pharmacodynamic antagonism. Use Caution/Monitor.

              • levodopa

                levodopa increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Consider decreasing dosage of antihypertensive agent.

              • lorcaserin

                lorcaserin will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • lornoxicam

                metoprolol and lornoxicam both increase serum potassium. Use Caution/Monitor.

                lornoxicam decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • losartan

                losartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, losartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • lurasidone

                lurasidone increases effects of metoprolol by Other (see comment). Use Caution/Monitor. Comment: Potential for increased risk of hypotension with concurrent use. Monitor blood pressure and adjust dose of antihypertensive agent as needed.

              • maraviroc

                maraviroc will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • marijuana

                marijuana will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • meclofenamate

                meclofenamate decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

                metoprolol and meclofenamate both increase serum potassium. Use Caution/Monitor.

              • mefenamic acid

                metoprolol and mefenamic acid both increase serum potassium. Use Caution/Monitor.

                mefenamic acid decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • mefloquine

                mefloquine increases levels of metoprolol by decreasing metabolism. Use Caution/Monitor. Risk of arrhythmia.

              • meloxicam

                metoprolol and meloxicam both increase serum potassium. Use Caution/Monitor.

                meloxicam decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • metaproterenol

                metoprolol increases and metaproterenol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of metaproterenol by pharmacodynamic antagonism. Use Caution/Monitor.

              • methyclothiazide

                metoprolol increases and methyclothiazide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

              • metolazone

                metoprolol increases and metolazone decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • mirabegron

                mirabegron will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • moxisylyte

                moxisylyte and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • nabumetone

                metoprolol and nabumetone both increase serum potassium. Use Caution/Monitor.

                nabumetone decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • nadolol

                metoprolol and nadolol both increase serum potassium. Use Caution/Monitor.

              • naproxen

                metoprolol and naproxen both increase serum potassium. Use Caution/Monitor.

                naproxen decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • nebivolol

                metoprolol and nebivolol both increase serum potassium. Use Caution/Monitor.

              • nicardipine

                metoprolol and nicardipine both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • nifedipine

                metoprolol and nifedipine both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • nilotinib

                nilotinib will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • nisoldipine

                metoprolol and nisoldipine both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • nitroglycerin rectal

                nitroglycerin rectal, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Beta-blockers blunt the reflex tachycardia produced by nitroglycerin without preventing its hypotensive effects. If beta-blockers are used with nitroglycerin in patients with angina pectoris, additional hypotensive effects may occur.

              • norepinephrine

                metoprolol increases and norepinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of norepinephrine by pharmacodynamic antagonism. Use Caution/Monitor.

              • olmesartan

                olmesartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, olmesartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • oxaprozin

                metoprolol and oxaprozin both increase serum potassium. Use Caution/Monitor.

                oxaprozin decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • oxymetazoline topical

                oxymetazoline topical increases and metoprolol decreases sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • panobinostat

                panobinostat will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Panobinostat can increase the levels and effects of sensitive CYP2D6 substrates or those with a narrow therapeutic index CYP2D6.

              • parecoxib

                parecoxib will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

                metoprolol and parecoxib both increase serum potassium. Use Caution/Monitor.

                parecoxib decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • peginterferon alfa 2b

                peginterferon alfa 2b, metoprolol. Other (see comment). Use Caution/Monitor. Comment: When patients are administered peginterferon alpha-2b with CYP2D6 substrates, the therapeutic effect of these drugs may be altered. Peginterferon alpha-2b may increase or decrease levels of CYP2D6 substrate.

              • penbutolol

                metoprolol and penbutolol both increase serum potassium. Use Caution/Monitor.

              • pentobarbital

                pentobarbital decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of pentobarbital. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • perphenazine

                perphenazine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • phenobarbital

                phenobarbital decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of phenobarbital. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • phenoxybenzamine

                phenoxybenzamine and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • phentolamine

                phentolamine and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • pindolol

                metoprolol and pindolol both increase serum potassium. Use Caution/Monitor.

              • pirbuterol

                metoprolol increases and pirbuterol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of pirbuterol by pharmacodynamic antagonism. Use Caution/Monitor.

              • piroxicam

                metoprolol and piroxicam both increase serum potassium. Use Caution/Monitor.

                piroxicam decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • ponesimod

                ponesimod and metoprolol both increase pharmacodynamic synergism. Use Caution/Monitor. Beta-blockers may have additive effects on lowering HR. Consider resting HR before initiating ponesimod in patients on stable dose of beta-blocker. Refer to the ponesimod prescribing information for more dosing information.

              • potassium acid phosphate

                metoprolol and potassium acid phosphate both increase serum potassium. Modify Therapy/Monitor Closely.

              • potassium chloride

                metoprolol and potassium chloride both increase serum potassium. Modify Therapy/Monitor Closely.

              • potassium citrate

                metoprolol and potassium citrate both increase serum potassium. Modify Therapy/Monitor Closely.

              • prazosin

                prazosin and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • primidone

                primidone decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of primidone. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • propafenone

                propafenone will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. If concurrent therapy is required, monitor cardiac function carefully, particularly blood pressure. A dosage adjustment for the beta blocker may be required.

              • propofol

                propofol, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • propranolol

                metoprolol and propranolol both increase serum potassium. Use Caution/Monitor.

              • quinacrine

                quinacrine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • ranolazine

                ranolazine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • rifabutin

                rifabutin decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Enzyme induction effect may continue for up to 3-4 weeks.

              • rifampin

                rifampin decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor.

              • rifapentine

                rifapentine decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor.

              • ritonavir

                ritonavir will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • rolapitant

                rolapitant will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Rolapitant may increase plasma concentrations of CYP2D6 substrates for at least 28 days following rolapitant administration.

              • sacubitril/valsartan

                sacubitril/valsartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, sacubitril/valsartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • salicylates (non-asa)

                metoprolol and salicylates (non-asa) both increase serum potassium. Use Caution/Monitor.

                salicylates (non-asa) decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • salmeterol

                metoprolol increases and salmeterol decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol decreases effects of salmeterol by pharmacodynamic antagonism. Use Caution/Monitor.

              • salsalate

                metoprolol and salsalate both increase serum potassium. Use Caution/Monitor.

                salsalate decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • saquinavir

                saquinavir, metoprolol. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Use alternatives if available. Increased risk of PR prolongation and cardiac arrhythmias.

              • secobarbital

                secobarbital decreases levels of metoprolol by increasing metabolism. Use Caution/Monitor. Consider a higher beta-blocker dose during coadministration of secobarbital. Atenolol, sotalol, nadolol less likely to be affected than other beta blockers.

              • sertraline

                sertraline will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • sevoflurane

                sevoflurane, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • sildenafil

                metoprolol increases effects of sildenafil by additive vasodilation. Use Caution/Monitor. Sildenafil has systemic vasodilatory properties and may further lower blood pressure in patients taking antihypertensive medications. Monitor blood pressure response to sildenafil in patients receiving concurrent blood pressure lowering therapy.

              • silodosin

                silodosin and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • siponimod

                siponimod, metoprolol. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Caution when siponimod is initiated in patients receiving beta-blocker treatment because of additive effects on lowering heart rate. Temporary interruption of beta-blocker may be needed before initiating siponimod. Beta-blocker treatment can be initiated in patients receiving stable doses of siponimod.

              • sodium bicarbonate

                sodium bicarbonate decreases levels of metoprolol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. Separate by 2 hours.

              • sodium citrate/citric acid

                sodium citrate/citric acid decreases levels of metoprolol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. Separate by 2 hours.

              • sotalol

                metoprolol and sotalol both increase serum potassium. Use Caution/Monitor.

              • spironolactone

                metoprolol and spironolactone both increase serum potassium. Modify Therapy/Monitor Closely.

              • succinylcholine

                metoprolol and succinylcholine both increase serum potassium. Use Caution/Monitor.

              • sulfasalazine

                metoprolol and sulfasalazine both increase serum potassium. Use Caution/Monitor.

                sulfasalazine decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • sulindac

                metoprolol and sulindac both increase serum potassium. Use Caution/Monitor.

                sulindac decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • tadalafil

                tadalafil increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.

              • telmisartan

                telmisartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, telmisartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • terazosin

                terazosin and metoprolol both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • terbinafine

                terbinafine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Assess need to reduce dose of CYP2D6-metabolized drug.

              • terbutaline

                metoprolol increases and terbutaline decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                metoprolol increases effects of terbutaline by pharmacodynamic synergism. Use Caution/Monitor.

                metoprolol decreases effects of terbutaline by pharmacodynamic antagonism. Use Caution/Monitor.

              • theophylline

                metoprolol, theophylline. Other (see comment). Use Caution/Monitor. Comment: Beta blockers (esp. non selective) antagonize theophylline effects, while at the same time increasing theophylline levels and toxicity (mechanism: decreased theophylline metabolism). Smoking increases risk of interaction.

              • thioridazine

                thioridazine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • timolol

                metoprolol and timolol both increase serum potassium. Use Caution/Monitor.

              • tipranavir

                tipranavir will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • tolfenamic acid

                metoprolol and tolfenamic acid both increase serum potassium. Use Caution/Monitor.

                tolfenamic acid decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • tolmetin

                metoprolol and tolmetin both increase serum potassium. Use Caution/Monitor.

                tolmetin decreases effects of metoprolol by pharmacodynamic antagonism. Use Caution/Monitor. Long term (>1 wk) NSAID use. NSAIDs decrease prostaglandin synthesis.

              • tolvaptan

                metoprolol and tolvaptan both increase serum potassium. Use Caution/Monitor.

              • torsemide

                metoprolol increases and torsemide decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • triamterene

                metoprolol and triamterene both increase serum potassium. Modify Therapy/Monitor Closely.

              • valsartan

                valsartan and metoprolol both increase serum potassium. Use Caution/Monitor.

                metoprolol, valsartan. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Risk of fetal compromise if given during pregnancy.

              • venlafaxine

                venlafaxine will increase the level or effect of metoprolol by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

              • verapamil

                metoprolol and verapamil both increase anti-hypertensive channel blocking. Modify Therapy/Monitor Closely.

              • xipamide

                xipamide increases effects of metoprolol by pharmacodynamic synergism. Use Caution/Monitor.

              Minor (32)

              • adenosine

                metoprolol, adenosine. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Bradycardia.

              • agrimony

                agrimony increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • antipyrine

                metoprolol increases levels of antipyrine by decreasing metabolism. Minor/Significance Unknown.

              • brimonidine

                brimonidine increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • cevimeline

                cevimeline increases effects of metoprolol by unspecified interaction mechanism. Minor/Significance Unknown.

              • ciprofloxacin

                ciprofloxacin increases levels of metoprolol by decreasing metabolism. Minor/Significance Unknown. Ciprofloxacin may increase metoprolol plasma concentrations however mechanism is unknown. Further clinical evidence is needed but it may be appropriate to monitor patients during concomitant therapy with ciprofloxacin.

              • cocaine

                metoprolol increases effects of cocaine by pharmacodynamic synergism. Minor/Significance Unknown. Risk of angina.

              • cornsilk

                cornsilk increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • diazepam

                metoprolol increases effects of diazepam by decreasing metabolism. Minor/Significance Unknown.

              • dihydroergotamine

                dihydroergotamine, metoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

              • dihydroergotamine intranasal

                dihydroergotamine intranasal, metoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

              • dipyridamole

                dipyridamole, metoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Risk of bradycardia.

              • escitalopram

                escitalopram increases levels of metoprolol by decreasing metabolism. Minor/Significance Unknown.

              • fenoldopam

                fenoldopam increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown. Additive hypotensive effects.

              • forskolin

                forskolin increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • guanfacine

                metoprolol, guanfacine. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Selective beta blocker administration during withdrawal from centrally acting alpha agonists may result in rebound hypertension.

              • imaging agents (gadolinium)

                metoprolol, imaging agents (gadolinium). Mechanism: unknown. Minor/Significance Unknown. Increased risk of anaphylaxis from contrast media.

              • levobetaxolol

                levobetaxolol increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • maitake

                maitake increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • melatonin

                melatonin decreases toxicity of metoprolol by pharmacodynamic antagonism. Minor/Significance Unknown. Melatonin may correct beta blocker induced sleep disturbances.

              • metipranolol ophthalmic

                metipranolol ophthalmic increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • neostigmine

                metoprolol, neostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

              • noni juice

                metoprolol and noni juice both increase serum potassium. Minor/Significance Unknown.

              • octacosanol

                octacosanol increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • oxazepam

                metoprolol increases effects of oxazepam by decreasing metabolism. Minor/Significance Unknown.

              • physostigmine

                metoprolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

              • pilocarpine

                pilocarpine increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • reishi

                reishi increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • shepherd's purse

                shepherd's purse, metoprolol. Other (see comment). Minor/Significance Unknown. Comment: Theoretically, shepherd's purse may interfere with BP control.

              • tizanidine

                tizanidine increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown. Risk of hypotension.

              • treprostinil

                treprostinil increases effects of metoprolol by pharmacodynamic synergism. Minor/Significance Unknown.

              • yohimbe

                metoprolol decreases toxicity of yohimbe by pharmacodynamic antagonism. Minor/Significance Unknown.

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              Adverse Effects

              No adverse effects specific to combination have been observed; adverse effects limited to those previously reported with metoprolol tartrate and hydrochlorothiazide

              1-10%

              Metoprolol tartrate

              • Bradycardia (3%), cold extremities(1%), constipation (1%), depression (5%), diarrhea (5%), dizziness (10%), dyspepsia (1%), dyspnea (3%), fatigue (10%), headache (10%), heart failure (1%), hypokalemiahypotension (1%), influenza-like symptomsnausea (1%), pruritus (5%), wheezing (1%)

              Hydrochlorothiazide

              • Anorexia, epigastric distress, hypokalemia, hypotension, phototoxicity

              Frequency Not Defined

              Metoprolol tartrate

              • Bronchospasm, mask symptoms of hypoglycemia

              Hydrochlorothiazide

              • Anaphylaxis, anemia, confusion, erythema multiforme skin reactions including Stevens-Johnson syndrome, exfoliative dermatitis including toxic epidermal necrolysis, hypomagnesemia, hyponatremia, hypochloremia, dizziness, fatigue, headache, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia, hypercholesterolemia, muscle weakness or cramps, nausea, purpura, rash, vertigo, vomiting

              Postmarketing Reports

              Hydrochlorothiazide

              • Non-melanoma skin cancer
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              Warnings

              Black Box Warnings

              May exacerbate ischemic heart disease following abrupt withdrawal

              Hypersensitivity to catecholamines has been observed during withdrawal

              Exacerbation of angina and, in some cases, myocardial infarction occurrence after abrupt discontinuation

              When discontinuing chronically administered beta-blockers (particularly with ischemic heart disease) gradually reduce dose over 1-2 weeks and carefully monitor

              If angina markedly worsens or acute coronary insufficiency develops, reinstate beta-blocker administration promptly, at least temporarily (in addition to other measures appropriate for unstable angina)

              Warn patients against interruption or discontinuation of beta-blocker without physician advice

              Because coronary artery disease is common and may be unrecognized, slowly discontinue beta-blocker therapy, even in patients treated only for hypertension

              Contraindications

              Anuria

              Cardiogenic shock

              CHF

              Heart block 2°/3°

              Hypersensitivity to either component or sulfonamides

              Overt cardiac failure

              Sick sinus syndrome (unless permanent pacemaker in place)

              Severe peripheral vascular disease

              Sinus bradycardia

              Cautions

              Anesthesia/surgery (myocardial depression); chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery, however the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures

              Avoid abrupt withdrawal

              Acute transient myopia and acute angle-closure glaucoma has been reported, particularly with history of sulfonamide or penicillin allergy (hydrochlorothiazide is a sulfonamide)

              Instruct patients to protect skin from sun and undergo regular skin cancer screening

              Bronchospastic disease

              Cerebrovascular insufficiency

              Cardiomegaly

              DM, fluid or electrolyte imbalance, hyperuricemia or gout, SLE

              Hyperthyroidism or thyrotoxicosis, liver disease

              May aggravate digitalis toxicity

              Peripheral vascular disease

              Pheochromocytoma

              Renal impairment

              Risk of male sexual dysfunction

              Sensitivity reactions may occur with or without history of allergy or asthma

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              Pregnancy & Lactation

              Pregnancy Category: C

              Lactation: excreted in breast milk, use caution

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Metoprolol/hydrochlorothiazide is a fixed-combination tablet that combines a beta adrenergic receptor blocker, metoprolol tartrate (Lopressor HCT) or metoprolol succinate (Dutoprol) and a thiazide diuretic, hydrochlorothiazide

              Metoprolol is a beta-1-selective (cardioselective) adrenergic blocking agent at low doses; at higher doses, it also inhibits beta-2 adrenoreceptors in the bronchial and vascular smooth muscles

              While the mechanism of the antihypertensive effects of beta-blocking agents has not been elucidated, it may involve competitive antagonism of catecholamines at peripheral (especially cardiac) adrenergic neuron sites, leading to decreased cardiac output; a central effect leading to reduced sympathetic outflow to the periphery; and suppression of renin activity

              Hydrochlorothiazide is a thiazide diuretic that inhibits Na reabsorption in distal renal tubules resulting in increased excretion of Na+ and water, also K+ and H+ ions

              Pharmacokinetics

              In comparison to immediate-release metoprolol (tartrate), the plasma metoprolol levels following administration of metoprolol succinate (long-acting) are characterized by lower peaks, longer time to peak and significantly lower peak to trough variation

              Bioavailability: 50% (metoprolol); (70%) hydrochlorothiazide

              Peak plasma concentration: 10-12 hr (metoprolol succinate); 2 hr (hydrochlorothiazide)

              Peak plasma time: 1.5-2 hr (metoprolol tartrate); 1.5-2.5 hr (hydrochlorothiazide)

              Onset: Initial diuresis from hydrochlorothiaizde (2 hr); antihypertensive effect: 3-4 days

              Duration: 3-6 hr (metoprolol tartrate); 6-12 hr (hydrochlorothiazide)

              Half-Life: 9-12 hr (metoprolol); 6-15 hr (hydrochlorothiazide)

              Clearance: hydrochlorothiazide 335 mL/min (hydrochlorothiazide)

              Excretion: Urine 95% (metoprolol) and 50-70% (hydrochlorothiazide)

              Dialyzable: No (hydrochlorothiazide)

              Distribution

              • Protein Bound: 12% (metoprolol); 40% (hydrochlorothiazide)
              • Vd: 5.6 L/kg (metoprolol); 3-4 L/kg (hydrochlorothiazide)

              Metabolism

              • Metoprolol: hepatic CYP2D6
              • Hydrochlorothiazide minimally metabolized
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              Formulary

              FormularyPatient Discounts

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              The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
              PA Prior Authorization
              Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
              QL Quantity Limits
              Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
              ST Step Therapy
              Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
              OR Other Restrictions
              Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.