Metoprolol SUCCINATE Twice Daily??

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Arkorous

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I have seen multiple times in practice a patient prescribed Metoprolol Succinate prescribed BID. The only recommended dosing for this extended release formulation I can find is once daily. I can find absolutely 0 literature on Metoprolol Succinate dosed twice daily. Am I severely missing something? What would be the benefits/drawbacks of Toprol XL twice daily?? My moms pharmacist even said it was fine. I'm lost. Any information anyone has is requested! :)
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it silly to do, but I see it all the time
 
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There is no advantage to it and the only disadvantage is more difficult regimen adherence. If the patient prefers it and remembers to take it, it’s fine.
 
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Not needed but I’ve seen weirder things.

If it makes you happy, haha
 
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Smoother PK. Same reason why some people are instructed to take Depakote ER (one daily formulation) twice a day. It's a smoother PK profile.

What does it mean clinically/practically? I don't know
 
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Since it's common practice to dose 400mg, it makes sense to manufacture Toprol XR 400mg. Before that happens, the next sensible thing is 200mg XR bid.
2 tab of 200mg once QD defeated the propose of XR to some extend but it's acceptable too. Just don't give 16 tab 25mg Toprol XR once QD.
 
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See it all the time too. Has anyone ever bothered to contact the doctor to find out what their reasoning is? Just out of curiosity.
 
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When I’ve seen it with the doctors I work with it’s often because they have no clue. Had an md argue for double statin therapy the other day lol
 
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One thing retail teaches you is deciding which battles to fight. You see a lot of silly things every day, but its better to simply leave the stupid, harmless things alone. I had gotten to the point I'd only attempt to bruise a doctor's ego when something was actually life threatening. The little stuff just ins't worth the fight, and it gave me the reputation that if I was calling on something it was usually important enough not to ignore...
 
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firework said:
Since it's common practice to dose 400mg, it makes sense to manufacture Toprol XR 400mg. Before that happens, the next sensible thing is 200mg XR bid.
2 tab of 200mg once QD defeated the propose of XR to some extend but it's acceptable too. Just don't give 16 tab 25mg Toprol XR once QD.
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in theory shouldn't it not matter? toprol xl 400mg take one daily = toprxol xl 200mg take two daily?
 
firework said:
12.5 mg XR bid doesn’t make any sense, I rarely saw that. Is it more expensive than 25 mg qd?
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This all stems from a family member being prescribed 12.5 mg BID. She splits the 25 mg tab in half and takes half in the morning and half at night per her physicians orders. Nothing to do with the cost at all. I convinced her to go back to one a day. She is also only on it for HTN as first line. But she has been on it since the 90s when it was more acceptable as first line.
 
In reality regimen sub-optimality is the norm (think of all the butthurt PCPs that react negatively to a fax about initiating statins like you are forcing them to write for one, or opioid overprescribing in the U.S.) so not sure why you would bat an eye over this.
 
Rouelle said:
Sometimes when I’m bored and have nothing more productive to do with my life I’ll cut my losartan in half and take 1/2 bid.

And yes I too see Toprol xl bid relatively frequently.
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Losartan kinetics are different because it may not last 24 hours in all patients: Efficacy and duration of action of the four selective angiotensin II subtype 1 receptor blockers, losartan, candesartan, valsartan and telmisartan, i... - PubMed - NCBI
You want the full dose in the morning to get the antihypertensive effect during waking hours. If you take it BID you’re shifting some BP lowering to overnight hours when it isn’t needed.
 
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owlegrad said:
I mean I am just glad when I see succinate BID rather than tartrate QD. At least one of those is only stupid, not harmful.
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this x1000 - funny thing is that I have trained my medication history technicians so well on potential errors and extended release mechanism - they call me everytime they see toprol bid to let me know they verified that is how the patient actually takes it - it now kinda gets annoying
 
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do you guys also cringe when there's a ppi "prn"? yikes.
 
or something like gabapentin or buspirone prn.....
 
Haha! You the new guy?

Relax.... you will find out that most prescribers don’t know what they are doing... And neither do most pharmacists. It won’t be long before you don’t know what your doing anymore also.

Metoprolol succinate bid? Happens constantly. Just fill it
 
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JustFillIt said:
Haha! You the new guy?

Relax.... you will find out that most prescribers don’t know what they are doing... And neither do most pharmacists. It won’t be long before you don’t know what your doing anymore also.

Metoprolol succinate bid? Happens constantly. Just fill it
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Haha I am new. I am also not a dispensing pharmacist. I was just wanting to see if there was any literature at all before I discuss it with a provider.
 
zelman said:
Losartan kinetics are different because it may not last 24 hours in all patients: Efficacy and duration of action of the four selective angiotensin II subtype 1 receptor blockers, losartan, candesartan, valsartan and telmisartan, i... - PubMed - NCBI
You want the full dose in the morning to get the antihypertensive effect during waking hours. If you take it BID you’re shifting some BP lowering to overnight hours when it isn’t needed.
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My story was that I noticed a lot of times my blood pressure was getting high around 7pm or so. I’m aware of the short effects of losartan and tried for a while to remedy this by taking a (half) dose first thing in the morning and repeating in the early afternoon (nowhere near a q12 interval). It seemed to help, although the study is inherently flawed because, among other reasons, I was most commonly measuring my evening BP while I was working a shift and most commonly doing the split dosing on my days off. I rarely do it anymore because qd dosing is easier to remember.
 
Rouelle said:
My story was that I noticed a lot of times my blood pressure was getting high around 7pm or so. I’m aware of the short effects of losartan and tried for a while to remedy this by taking a (half) dose first thing in the morning and repeating in the early afternoon (nowhere near a q12 interval). It seemed to help, although the study is inherently flawed because, among other reasons, I was most commonly measuring my evening BP while I was working a shift and most commonly doing the split dosing on my days off. I rarely do it anymore because qd dosing is easier to remember.
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You may have ultra-rapid 2C9 metabolism genes. Maybe find a drug with a different metabolic pathway?
 
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I work at a heart failure clinic. The goal is to get patients on guideline directed medical therapy. Often times patients are unable to tolerate being on a beta blocker due to hypotension. We do split dosing and walk up the dose 12.5mg at a time until they are the maximum tolerated dose. We do the same with ace-i and arbs. We have better success at up titrations this way and our patients heart failure symptoms improve.
 
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GravityBeetle said:
See it all the time too. Has anyone ever bothered to contact the doctor to find out what their reasoning is? Just out of curiosity.
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Yes the md says "because the patient claims it works better"
 
Xenophylia said:
One thing retail teaches you is deciding which battles to fight. You see a lot of silly things every day, but its better to simply leave the stupid, harmless things alone. I had gotten to the point I'd only attempt to bruise a doctor's ego when something was actually life threatening. The little stuff just ins't worth the fight, and it gave me the reputation that if I was calling on something it was usually important enough not to ignore...
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Not just retail. Ive only had a few hard f no. The RNs are so shocked that even if the MD disagrees with me the RNs usually refuse to give. Im talking flumazenil to the chronic BZD OD who is just drowsy but protecting airway silliness.
 
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Agree with the OP frustration on limited information on metoprolol succinate pharmacokinetics and bid dosing. Searching today, in January 2024, this is the only relevant thread on the topic, and there are no publications. If you would have it - a personal experience. Taking metoprolol succinate 25mg/day once daily in the morning after breakfast, I found that each morning I had a queasy feeling and racing heartrate until I took the next dose. My specialist cardiologist in Boston recommended bid dosing, even though the formulation is "extended release". Making that switch, I am tolerating therapy again. I believe that it is logical to believe that extended release is not guarantee to have full 24 hour coverage for all patient populations, and twice daily dosing might make sense for some people. Sure, I would like published data to support it. Maybe even in-vitro dissolution profiles, my goodness. However, here is a single first-person attestation that also follows first principals.
 
Yes, this is a common practice at my hospital. As mentioned above, the belief is that it offers smoother kinetics than doing tartrate twice daily.
 
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mustang sally said:
Yes, this is a common practice at my hospital. As mentioned above, the belief is that it offers more smoother kinetics than doing tartrate twice daily.
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Quite a few of the above posts cast doubt on bid dosing and suggest it comes from error or ignorance. I hope future students can see a more balanced perspective. That single pretty PK data is a cleaned-up average of many profiles.
 
see it all the time. I espically like it when its XL and they say 1/2 tablet :rolleyes:
 
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I had new rx sent for metoprolol twice one is IR and other XR. I thought maybe MD made mistake when sent it. When I called first thing he send I am board certified cardiologist you know nothing. All I needed to make sure 🤦‍♀️
 
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