Carvedilol + Metoprolol Combination

[EC21]

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Hello all. I am a pharmacist & saw a pt on both carvedilol and metoprolol. Under what circumstances would these be combined? I searched & cannot really find any but maybe am looking in the wrong place.

 

[trailerpark]

They're both the heart failure ones, but no idea.

 

[WhiteSnows]

No they should not be combined. They may be written by two different doctors.

 

[EC21]

They're both the heart failure ones, but no idea.

Same MD. Verified & the MD is insistent on the combination. I think it is an extraordinarily poor choice with no medical justification, but I wonder if I am missing something.....

 

[maria1oh]

What are the strengths on the medications? I would feel ok dispensing them both at lower doses.

 

[EC21]

What are the strengths on the medications? I would feel ok dispensing them both at lower doses.

Strengths are Coreg 25mg 1BiD, Toprol XL 100mg 1QD, so hefty doses. It worries me but the pt has been on since 2012 & the MD verified & insisted upon the combination & doses.

 

[WhiteSnows]

Strengths are Coreg 25mg 1BiD, Toprol XL 100mg 1QD, so hefty doses. It worries me but the pt has been on since 2012 & the MD verified & insisted upon the combination & doses.

90% this combination is for HF. But there is no study conclude the benefits of combining both. May the patient is fine and the MD does not want to mess with the dose. This must be a rare case that I will move one.

 

[Sunshine98]

I have 1 patient like that. Don't know the reasoning, but verified with the doctor. Mine in on Coreg 12.5 bid and Toprol XL 25 one-half tablet qd

 

[EC21]

90% this combination is for HF. But there is no study conclude the benefits of combining both. May the patient is fine and the MD does not want to mess with the dose. This must be a rare case that I will move one.

I don't get the reasoning of "because he's been on it" &/or "seems to be fine", especially because everything is fine, till it's not. I am not going to worry too much since our documentation is complete.
I have just got some weird combinations of meds recently that makes me wish I knew a MD & could ask them, "why would someone prescribe that?"

 

[WhiteSnows]

I don't get the reasoning of "because he's been on it" &/or "seems to be fine", especially because everything is fine, till it's not. I am not going to worry too much since our documentation is complete.
I have just got some weird combinations of meds recently that makes me wish I knew a MD & could ask them, "why would someone prescribe that?"

This will not be the only weird thing you see in practice. A lot of times the patient is on it for many years and no side effects have been reported. We just keep the way it is. Since your patient body is adjusted to accommodate these 2 meds. Withdrawing one can cause harm than good. So, a lot of times we just leave the way it is.

 

[zelman]

In some regions MD's use FDA approved doses, guidelines, and evidence based medicine. In others MD's act like prescribing is an impressionist painting. Figure out which you're in, accept it, and life will be easier.

 

[Ackj]

Doesn't make a ton of sense, but if I had to come up with a reason, I would say it's because the carvedilol has the mixed alpha/beta effect. Why not just add a pure alpha blocker and dial in the metoprolol dose? Who knows.

 

[atpsynthase]

Yup. I've come across this a few times. Some cardiologists like using carvedilol first due to a more complete adrenergic blockade (blunting more of the compensatory responses aggravated during HF) and adding an additional beta-1 selective antagonist if necessary later to improve HF symptoms.

Also, carvedilol has been shown to be more effective than metoprolol in some HF patients, so using carvedilol + metoprolol may be preferred by the cardiologist over an alpha blocker + metoprolol in a specific set of patients. Carvedilol may also be better tolerated than pure alpha blockers.

 

[EC21]

In some regions MD's use FDA approved doses, guidelines, and evidence based medicine. In others MD's act like prescribing is an impressionist painting. Figure out which you're in, accept it, and life will be easier.

Ha ha, that is easily the best analogy I have ever seen. Tks.

 

[EC21]

Yup. I've come across this a few times. Some cardiologists like using carvedilol first due to a more complete adrenergic blockade (blunting more of the compensatory responses aggravated during HF) and adding an additional beta-1 selective antagonist if necessary later to improve HF symptoms.

Also, carvedilol has been shown to be more effective than metoprolol in some HF patients, so using carvedilol + metoprolol may be preferred by the cardiologist over an alpha blocker + metoprolol in a specific set of patients. Carvedilol may also be better tolerated than pure alpha blockers.

Interesting. I guess this is the best mechanistic answer. Thanks!