Metoprolol

What is metoprolol?

Metoprolol is a beta-blocker that affects the heart and circulation (blood flow through arteries and veins).
Metoprolol is used to treat angina (chest pain) and hypertension (high blood pressure). It is also used to treat or prevent heart attack.
Metoprolol may also be used for other purposes not listed in this medication guide.

Important information

You should not use metoprolol if you have a serious heart problem (heart block, sick sinus syndrome, slow heart rate), severe circulation problems, severe heart failure, or a history of slow heart beats that caused fainting.

 

You should not use this medication if you are allergic to metoprolol, or other beta-blockers (atenolol, carvedilol, labetalol, nadolol, nebivolol, propranolol, sotalol, and others), or if you have:

• a serious heart problem such as heart block, sick sinus syndrome, or slow heart rate;
  
• severe circulation problems;
  
• severe heart failure (that required you to be in the hospital); or
  
• history of slow heart beats that have caused you to faint.
  

To make sure metoprolol is safe for you, tell your doctor if you have:

• asthma, chronic obstructive pulmonary disease (COPD), sleep apnea, or other breathing disorder;
  
• diabetes (taking metoprolol may make it harder for you to tell when you have low blood sugar);
  
• liver disease;
  
• congestive heart failure;
  
• problems with circulation (such as Raynaud's syndrome);
  
• a thyroid disorder; or
  
• pheochromocytoma (tumor of the adrenal gland).
  

FDA pregnancy category C. It is not known whether metoprolol will harm an unborn baby. Tell your doctor right away if you become pregnant while using this medication.
See also: Pregnancy and breastfeeding warnings (in more detail)
Metoprolol can pass into breast milk and may harm a nursing baby. Tell your doctor if you are breast-feeding a baby.
Metoprolol is not approved for use by anyone younger than 18 years old.

How should I take metoprolol?

Take metoprolol exactly as prescribed by your doctor. Follow all directions on your prescription label. Your doctor may occasionally change your dose to make sure you get the best results. Do not take this medicine in larger or smaller amounts or for longer than recommended.
Take the medicine at the same time each day.
Metoprolol should be taken with a meal or just after a meal.
A Toprol XL tablet can be divided in half if your doctor has told you to do so. The half tablet should be swallowed whole, without chewing or crushing.
While using metoprolol, you may need frequent blood tests at your doctor's office. Your blood pressure will need to be checked often.
If you need surgery, tell the surgeon ahead of time that you are using metoprolol.
You should not stop using metoprolol suddenly. Stopping suddenly may make your condition worse.
If you are being treated for high blood pressure, keep using this medication even if you feel well. High blood pressure often has no symptoms. You may need to use blood pressure medication for the rest of your life.
Store metoprolol at room temperature away from moisture and heat.
See also: Dosage Information (in more detail)

What happens if I miss a dose?

Take the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

What should I avoid?

Metoprolol may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.
Drinking alcohol can increase certain side effects of metoprolol.

Metoprolol side effects

Get emergency medical help if you have any signs of an allergic reaction to metoprolol: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have:

• very slow heartbeats;
  
• a light-headed feeling, like you might pass out;
  
• shortness of breath (even with mild exertion), swelling, rapid weight gain; or
  
• cold feeling in your hands and feet.
  

Common metoprolol side effects may include:

• dizziness, tired feeling;
  
• confusion, memory problems;
  
• nightmares, trouble sleeping;
  
• diarrhea; or
  
• mild itching or rash.
  

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
See also: Side effects (in more detail)

Metoprolol dosing information

Usual Adult Dose of Metoprolol for Angina Pectoris Prophylaxis:
Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 450 mg/day.
Extended release may be used at the same total daily dose given once a day.
Usual Adult Dose for Hypertension:
Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 450 mg/day.
Extended release may be used at the same total daily dose given once a day.
Usual Adult Dose for Supraventricular Tachycardia:
Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 450 mg/day.
Extended release may be used at the same total daily dose given once a day.
Usual Adult Dose of Metoprolol for Angina Pectoris:
Initial dose: 100 mg orally in 1 or 2 divided doses.
Maintenance dose: 100 to 400 mg/day.
Extended release may be used at the same total daily dose given once a day.
Usual Adult Dose for Myocardial Infarction:
Early treatment:
IV: 3 bolus injections of 5 mg given at 2 minute intervals.
Oral: In patients who tolerate the full IV dose (15 mg), metoprolol tablets, 50 mg every 6 hours, should be initiated 15 minutes after the last IV dose and continued for 48 hours. Maintenance dose: 100 mg orally twice a day.
Patients who appear not to tolerate the full IV dose should be started on metoprolol tablets at 25 mg or 50 mg every 6 hours 15 minutes after the last intravenous dose or as soon as their clinical condition allows.

Late treatment:
Oral: 100 mg orally twice a day.
Patients with contraindications to treatment during the early phase of suspected or definite myocardial infarction, patients who appear not to tolerate the full early treatment, and patients in whom the physician wishes to delay therapy for any other reason should be started on metoprolol tablets as soon as their clinical condition allows.
Usual Adult Dose for Congestive Heart Failure:
Initial dose: 25 mg once daily (of the XL formulation) for two weeks in patients with NYHA class II heart failure and 12.5 mg once daily (of the XL formulation) in patients with more severe heart failure.
Maintenance dose: This dosage should then be doubled every two weeks to the highest dosage level tolerated or up to 200 mg.

If transient worsening of heart failure occurs, it may be treated with increased doses of diuretics, and it may also be necessary to lower the dose or temporarily discontinue treatment. The dose should not be increased until symptoms of worsening heart failure stabilize.

Initial difficulty with titration should not preclude later attempts to institute therapy. If heart failure patients experience symptomatic bradycardia, the dose should be reduced.
Usual Pediatric Dose of Metoprolol for Hypertension:
Immediate release:
1 to 17 years:
Initial dose: 1 to 2 mg/kg/day, administered in 2 divided doses. Dosage should be adjusted based on patient response.
Maximum dose: 6 mg/kg/day (less than or equal to 200 mg/day)

Extended release:
6 to 16 years:
Initial dose: 1 mg/kg orally once daily (not to exceed 50 mg once daily). The minimum available dose is one half of the 25 mg tablet.
Maintenance dose: Dosage should be adjusted according to blood pressure response. Doses above 2 mg/kg (or in excess of 200 mg) once daily have not been studied.

What other drugs will affect metoprolol?

Tell your doctor about all medicines you use, and those you start or stop using during your treatment with metoprolol, especially:

• prazosin;
  
• terbinafine;
  
• an antidepressant - bupropion, clomipramine, desipramine, duloxetine, fluoxetine, fluvoxamine, paroxetine, sertraline;
  
• an ergot medicine - dihydroergotamine, ergonovine, ergotamine, methylergonovine;
  
• heart or blood pressure medications - amlodipine, clonidine, digoxin, diltiazem, dipyridamole, hydralazine, methyldopa, nifedipine, quinidine, reserpine, verapamil, and others;
  
• a MAO inhibitor - isocarboxazid, linezolid, phenelzine, rasagiline, selegiline, tranylcypromine; or
  
• medicine to treat mental illness - chlorpromazine, fluphenazine haloperidol, thioridazine.
  

This list is not complete. Other drugs may interact with metoprolol, including prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible interactions are listed in this medication guide.

what is Cetirizine?

What is cetirizine?

Cetirizine is an antihistamine that reduces the natural chemical histamine in the body. Histamine can produce symptoms of sneezing, itching, watery eyes, and runny nose. It is used to treat cold or allergy symptoms such as sneezing, itching, watery eyes, or runny nose.
Cetirizine is also used to treat itching and swelling caused by hives.
Cetirizine may also be used for other purposes not listed in this medication guide.

Important information

Cetirizine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid drinking alcohol. It can increase some of the side effects of cetirizine. Tell your doctor if you regularly use other medicines that make you sleepy (such as other cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression, or anxiety). They can add to sleepiness caused by cetirizine. Call your doctor if your symptoms do not improve, if they get worse, or if you also have a fever.

Before taking this medicine

You should not use this medication if you are allergic to cetirizine. Before taking cetirizine, tell your doctor about all of your medical conditions.

FDA pregnancy category B. This medication is not expected to be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Cetirizine can pass into breast milk and may harm a nursing baby. Do not use cetirizine without telling your doctor if you are breast-feeding a baby. Older adults may need to take a lower than normal dose. Follow your doctor's instructions.

 

How should I take cetirizine?

Take cetirizine exactly as directed on the label, or as prescribed by your doctor. Do not use it in larger amounts or for longer than recommended.

You may take cetirizine with or without food.
The chewable tablet must be chewed before you swallow it.
Measure liquid medicine with a special dose-measuring spoon or cup, not a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist for one.
Call your doctor if your symptoms do not improve, if they get worse, or if you also have a fever. Store cetirizine at room temperature away from moisture and heat. See also: Dosage Information (in more detail)

What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, wait until then to take the medicine and skip the missed dose. Do not take extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. Overdose symptoms may include feeling restless or nervous, and then feeling drowsy.

What should I avoid?

Tell your doctor if you regularly use other medicines that make you sleepy (such as other cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression, or anxiety). They can add to sleepiness caused by cetirizine. Cetirizine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid drinking alcohol. It can increase some of the side effects of cetirizine.

 

Cetirizine side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using cetirizine and call your doctor at once if you have any of these serious side effects:

• fast, pounding, or uneven heartbeat;
  
• weakness, tremors (uncontrolled shaking), or sleep problems (insomnia);
  
• severe restless feeling, hyperactivity;
  
• confusion;
  
• problems with vision; or
  
• urinating less than usual or not at all.
  

Less serious side effects may include:

• dizziness, drowsiness;
  
• tired feeling;
  
• dry mouth;
  
• sore throat, cough;
  
• nausea, constipation; or
  
• headache.
  

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.
See also: Side effects (in more detail)

What other drugs will affect cetirizine?

There may be other drugs that can interact with cetirizine. Tell your doctor about all your prescription and over-the-counter medications, vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start a new medication without telling your doctor.
More frequently reported side effects include: abdominal pain, drowsiness, and fatigue. See below for a comprehensive list of adverse effects.

For the Consumer

Applies to cetirizine: oral solution, oral tablets and chewable tablets
Side effects include:
Adults and children ≥12 years of age: Somnolence, fatigue, dry mouth. Insomnia reported with cetirizine hydrochloride-pseudoephedrine hydrochloride fixed combination.
Children 2–11 years of age: Headache, pharyngitis, abdominal pain.
Children 6 months to 2 years of age: Irritability, fussiness, insomnia, fatigue, malaise.

For Healthcare Professionals

Applies to cetirizine: oral capsule, oral liquid, oral syrup, oral tablet, oral tablet chewable, oral tablet dispersible

Nervous system

Nervous system side effects have included headache (16%), fatigue (5.6%), and somnolence (5% to 20%). Somnolence tends to be dose-related and generally occurs more frequently with doses higher than 10 mg per day. Other nervous system side effects include dizziness (1.8%), insomnia (1.5%), and nervousness (1.1%). Post marketing reports have included aggression reaction and convulsions.^[Ref]
Cetirizine appears to be more sedating than loratadine.^[Ref]

Gastrointestinal

Gastrointestinal side effects have included dry mouth (5.7%) and nausea or vomiting (2.2%). Pharyngitis, dyspepsia, and increased appetite have occasionally been reported.^[Ref]

Hepatic

Hepatic side effects have included rare liver function test abnormalities which resolved spontaneously following discontinuation of cetirizine therapy. At least one case of recurrent acute hepatitis has also been associated with cetirizine use.^[Ref]

Respiratory

Respiratory side effects have included relatively rare reports of wheezing, coughing, bronchitis, sinusitis, and asthma.^[Ref]

Dermatologic

Dermatologic side effects have included reports of maculopapular and urticarial eruptions. Fixed drug eruptions have also been associated with cetirizine.^[Ref]

General

General side effects have included epistaxis (1.1%) and accidental injury (1.1%).^[Ref]

Hypersensitivity

Hypersensitivity side effects have included a case report of an anaphylactic reaction.^[Ref]

Psychiatric

Delusional thinking and depression has been reported in an 18-year-old woman started on cetirizine; the symptoms resolved once cetirizine was discontinued.^[Ref]
Postmarketing psychiatric side effects have included reports of aggressive reaction, hallucinations, suicidal ideation and suicide.^[Ref]

References

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2. Spencer CM, Faulds D, Peters DH "Cetirizine. A reappraisal of its pharmacological properties and therapeutic use in selected allergic disorders." Drugs 46 (1993): 1055-80

3. Lockey RF, Widlitz MD, Mitchell DQ, Lumry W, Dockhorn R, Woehler T, Grossman J "Comparative study of cetirizine and terfenadine versus placebo in the symptomatic management of seasonal allergic rhinitis." Ann Allergy Asthma Immunol 76 (1996): 448-54

4. Salmun LM, Gates D, Scharf M, Greiding L, Ramon F, Heithoff K "Loratadine versus cetirizine: Assessment of somnolence and motivation during the workday." Clin Ther 22 (2000): 573-82

5. Takahashi H, Ishida-Yamamoto A, Iizuka H "Effects of bepotastine, cetirizine, fexofenadine, and olopatadine on histamine-induced wheal-and flare-response, sedation, and psychomotor performance." Clin Exp Dermatol 29 (2004): 526-32

6. Adelsberg BR "Sedation and performance issues in the treatment of allergic conditions." Arch Intern Med 157 (1997): 494-500

7. Campoli-Richards DM, Buckley MM, Fitton A "Cetirizine. A review of its pharmacological properties and clinical potential in allergic rhinitis, pollen-induced asthma, and chronic urticaria." Drugs 40 (1990): 762-81

8. Shamsi Z, Kimber S, Hindmarch I "An investigation into the effects of cetirizine on cognitive function and psychomotor performance in healthy volunteers." Eur J Clin Pharmacol 56 (2001): 865-71

9. Hannuksela M, Kalimo K, Lammintausta K, Mattila T, Turjanmaa K, Varjonen E, Coulie PJ "Dose ranging study: cetirizine in the treatment of atopic dermatitis in adults." Ann Allergy 70 (1993): 127-33

10. Breneman D, Bronsky EA, Bruce S, Kalivas JT, Klein GL, Roth HL, Tharp MD, Treger C, Soter N "Cetirizine and astemizole therapy for chronic idiopathic urticaria: a double-blind, placebo-controlled, comparative trial." J Am Acad Dermatol 33 (1995): 192-8

11. "Product Information. Zyrtec (cetirizine)." Pfizer US Pharmaceuticals, New York, NY.

12. Desager JP, Horsmans Y "Pharmacokinetic pharmacodynamic relationships of h-1-antihistamines." Clin Pharmacokinet 28 (1995): 419-32

13. Sannita WG, Crimi E, Riela S, Rosadini G, Brusasco V "Cutaneous antihistaminic action of cetirizine and dose-related EEG concomitants of sedation in man." Eur J Pharmacol 300 (1996): 33-41

14. Rihoux JP, Mariz S "Cetirizine. An updated review of its pharmacological properties and therapeutic efficacy." Clin Rev Allergy 11 (1993): 65-88

15. Simons FER, Fraser TG, Reggin JD, Simons KJ "Comparison of the central nervous system effects produced by six h-1-receptor antagonists." Clin Exp Allergy 26 (1996): 1092-7

16. Breneman DL "Cetirizine versus hydroxyzine and placebo in chronic idiopathic urticaria." Ann Pharmacother 30 (1996): 1075-9

17. Spector SL, Nicodemus CF, Corren J, Schanker HM, Rachelefsky GS, Katz RM, Siegel SC "Comparison of the bronchodilatory effects of cetirizine, albuterol, and both together versus placebo in patients with mild-to-moderate asthma." J Allergy Clin Immunol 96 (1995): 174-81

18. Reunala T, Brummer-Korvenkontio H, Karppinen A, Coulie P, Palosuo T "Treatment of mosquito bites with cetirizine." Clin Exp Allergy 23 (1993): 72-5

19. Grant JA, Nicodemus CF, Findlay SR, Glovsky MM, Grossman J, Kaiser H, Meltzer EO, Mitchell DQ, Pearlman D, Selner J, Settipa "Cetirizine in patients with seasonal rhinitis and concomitant asthma: prospective, randomized, placebo-controlled trial." J Allergy Clin Immunol 95 (1995): 923-32

20. Pompili M, Basso M, Grieco A, Vecchio FM, Gasbarrini G, Rapaccini GL "Recurrent acute hepatitis associated with use of cetirizine." Ann Pharmacother 38 (2004): 1844-7

21. Calista D, Schianchi S, Morri M "Urticaria induced by cetirizine." Br J Dermatol 144 (2001): 196

22. Stingeni L, Caraffini S, Agostinelli D, Ricci F, Lisi P "Maculopapular and urticarial eruption from cetirizine." Contact Dermatitis 37 (1997): 249-50

23. Mahajan VK, Sharma NL, Sharma VC "Fixed drug eruption: a novel side-effect of levocetirizine." Int J Dermatol 44 (2005): 796-8

24. Kranke B, Kern T "Multilocalized fixed drug eruption to the antihistamine cetirizine." J Allerg Clin Immunol 106 (2001): 988

25. Karamfilov T, Wilmer A, Hipler UC, Wollina U "Cetirizine-induced urticarial reaction." Br J Dermatol 140 (1999): 979-80

26. Afonso N, Shetgaonkar P, Dang A, Rataboli PV "Cetirizine-induced anaphylaxis: a rare adverse drug reaction." Br J Clin Pharmacol 67 (2009): 577-8

27. Garden BC, Francois D "Cetirizine-associated delusions and depression in an 18-year-old woman." Clin Neuropharmacol 36 (2013): 96-7

Not all side effects for cetirizine may be reported. You should always consult a doctor or healthcare professional for medical advice. Side effects can be reported to the FDA here.