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Metoprolol Extended Release Withdrawal
Hi, I’m new here. First, I suffer from anxiety, esp health and medication anxiety. I’m certain many will roll their eyes at this post, but my concern is real to me. Also, I already know I’ve done a stupid thing by trying to wean off without talking to my doctor. So please don’t lecture me about that. I’ve researched this quite a bit over the last week.
Back in late 2019 I was having heart palps. I’ve always had some here and there but there was a period where they got worse and weren’t going away. I saw a cardiologist who did all the usual, an ECG, echo, stress test, holter monitor. His notes said: ECG-NSR (is that normal sinus rhythm?), Echo-Essentially normal, Holter-SR, frequent APCs associated with reported palpitations, Treadmill Test-Normal at 9:30 minutes. He said everything was fine and they were benign palps. He prescribed 10mg propranolol to take as needed. The palps stopped on their own and I never even tried the medication.
Enter COVID and my health anxiety went through the roof. During the lock downs my BP was spiking to hypertensive crisis levels and scaring me, but when I was able to get calm it was normal or only slightly elevated. I had several phone appointments with the same cardiologist and he ended up prescribing metoprolol extended release. I started at 25mg and immediately cut to 12.5mg, but both doses had my BP going too low. I ended up quartering the 25mg tablet. So I was taking 6.25mg and my cardiologist was aware. His notes say: palps well controlled with low dose metoprolol 1/4 of 25mg pill. In 2021, per a phone appointment he switched me to propranolol 10mg every 4-6 hours as needed for palps. I think it was bc I was concerned the metoprolol was still taking my BP low. I never made the change though and have stayed on the 6.25mg ever since, because I don’t like messing with medication due to my anxiety.
Then my cardiologist moved to another state. I didn’t find a new cardiologist but did find a new primary care Dr bc my old one moved way across town. As my prescription was running out, I provided her with my med records from the cardiologist and she refilled the metoprolol prescription with me quartering the 25mg tablet for a daily dose of 6.25mg. She did also write me the same propanolol 10mg prescription for twice a day (but I remember her saying I could take it only once a day if I wanted) in case I ever wanted to try that instead. She commented that metoprolol is a strong medication. I never did switch and stayed on the 6.25mg of metoprolol.
Last Monday, I took my BP prior to my morning meds and noticed that my HR was in the mid 40s. That triggered my health anxiety and I didn’t take the metoprolol that day and decided I shouldn’t be taking this at all and I started reading about how to wean off it. Yes, I know you should consult your Dr but mine is out of town until April. After much research, I decided that because I really can’t get any lower on this dose (and I suspect a Dr if asked is going to sigh and say just stop it), I decided to cut it in half yet again (now I’m getting around 3.12mg) and take that for a week, then take the 3.12mg every other day for another week, then stop.
I’m on day 6 of the 3.12mg and I’ve noticed a lot of more anxiety (probably a combination of the reduced dose and my medication anxiety) and that my HR walking around the house doing light housework is going up in the low 100s. Frankly, I don’t know what it normally is, but I convinced myself it was too high. It’s hard to say if it’s the reduction, my anxiety, or a combination. My BP is about like it always is with a few spikes when I was super anxious, but they came back down when I calmed down.
So, with this information, I don’t know if I should go back to my usual dose and wait to talk to my Dr when she returns in April, or if I should hold at this new dose and wait to talk to her. I’ve scared myself too much to try to continue the taper.
Thank you for reading all this. I know I’m a mess.
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Hi,
You have an interesting situation which I really can't help with. I think that the Cardiologists (aka Pill prescribers) need constant training. My 1st cardiologist started me off with 40mg Atorvastatin- a high rate. My 2nd cardiologist reduced it to 10mg since my Lipid panel blood work is very low:
LIPID PANEL
Lab tests - Blood
Results
Cholesterol
Normal range: below < 200 MG/DL
Value
95
CHOL. RISK FACTORS FOR C.H.D. FOR ADULT PATIENTS ONLY
< 200 MG/DL: DESIRABLE
200-239 MG/DL: BORDERLINE/HIGH RISK
240 OR >240 MG/DL: HIGH RISK
Non-HDL Cholesterol
Value
54
PLEASE NOTE THAT CHOL (-HDL) IS A CALCULATED TEST DERIV
ED FROM TOTAL CHOLESTEROL MINUS HDL. NCEP RECOMMENDS A TARGET GOAL OF 30 MG/DL MORE THAN THE TARGET GOAL FOR LDL.
HDL
Normal range: above >39 MG/DL
Value
41
Triglycerides
Normal range: below < 150 MG/DL
Value
95
LDL
Normal range: below < 100 MG/DL
Value
35
My 1st cardiologist should have started me low and increased it to get to the desired numbers!
I was taking 2.5 mg Amlodipine Besylate to lower Blood pressure but it gave me swollen legs.
I now only take it if the Systolic is over 140 otherwise I take 1/2 tab of 25mg (1.2mg) Metoprolol Tartrate . I don't take anything is Systolic is < 110 or hear rate is < 60. It's interesting that my General practitioner told me Systolic in the 130's is OK for older people-I'm 81.
Some cardiologists don't give med unless Systole is over 150. My brother is normally over 150 but his cardiologist would rather him have high blood pressure than low. His gets very low on occasion. Hope you enjoyed my input.
Good luck!
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3 ReactionsI acknowledge your anxiety and worries. Please let me explain some terminology and some of what I understand, and have experienced.
The medical community deals not only with diseases and disorders, but they take their cues from their patients about what they sense and how they feel as their patients describe these things. In other words, symptoms and 'how I feel' are exceedingly important because a person can get worn down if their anxieties and sensations are discounted. The doctors and nurses are, or ought to be, acutely interested in what you tell them, and not just with what their devices and textbooks tell them. They ought to 'listen'. Mitigation of symptoms are huge in the medical establishment, and for good reason.
Some terminology:
Palpitations are what the patient attempts to describe about what they feel. They are not a 'diagnosis' per se. They only are what we sense when our hearts beat either rapidly or out of proper rhythm. I mean the thumps, bumps, feeling of swelling in the chest, and so on.
The other term you mentioned APCs is actually PAC, or premature atrial contractions. This is sort of half an arrythmia. They do cause palpitations because so many patients say they feel palpitations while they are having PACs. What happens is the atrium contracts, then misses a beat, and then makes it up suddenly and it is out of sequence with the rest of the heart. So, there's a pressure surge from the lower chambers trying to pump blood out of the heart (both lower ventricles, the big pumps, push blood out of the heart). However, the out-of-sequence atrial beat is trying to force blood into the ventricle at the same time, so there's almost a double whammy of pressure buildup. You feel the thump.
NSR is indeed 'normal sinus rhythm'. PACs take place during NSR, and not during other arrhytmias such as flutter or fibrillation.
The heart does get used to beta blockers over time, but not because it just doesn't notice it after a while. It creates new channels for calcium and new adrenergic receptors as it tries to recover from the effects of the blocker such as metoprolol. You should taper, but it needn't be an absolute thing, especially for your low dose. Even so, the taper you describe ought to have sufficed.
I was told to stop metoprolol when my first catheter ablation failed within days and I was in the ER with a heart rate upwards of 140. The EKG showed fibrillation, but my ventricular rate was down to the high 30s, and my heart actually stopped several times, causing the nurse to rush in only to find me still talking with my wife. The internist decided to stop metoprolol because it was causing my heart to beat at the AV node survival rate of 30 BPM. Instead, I went on a six week regimen of 400mg/day of Amiodarone, the anti-arrhythmic drug of last resort (yes, google will tell you that if you ask that question). I don't want to go on about this, but my message is that one CAN stop metoprolol on a dime if absolutely necessary, but you would almost certainly have to have some kind of a substitute or anti-arrhythmic drug like Flecainide, Multaq, Sotolol, propafenone, or another rate control like diltiazem.
It is unusual to have PACs with an HR upwards of 100 BPM. My medical team, and the information pamphlets handed to me after my catheter ablation, urged me to not let my HR exceed 100 BPM for more than 24 hours, particularly after the actual procedure. But, over on afibbers.org forum, we tell people that even if they're still awaiting a formal procedure or assessment to not wait more than 24 hours with their hearts upwards of 100 BPM because it signifies distress of some kind, probably atrial fibrillation. The heart can tire if left in arrhythmia with a high rate for too long.
I would advise against getting wrapped around the axle over an HR in the low 40s. If you are at rest, calm, and are not feeling unwell, then you can easily rest at 40 BPM. It's technically bradycardia even at 49 BPM, but many people who are fit and healthy, as I was until recently, have resting heart rates and waking heart rates in the morning closer to 30 BPM. Mine was 34 when I was a competitive runner years ago.
I can see no literature that links anxiety to increases or decreases of dosage of metoprolol, or even if one takes or ceases to take, metoprolol. I hope you will accept my suggestion in the spirit of good will in which I give it, but you might avail yourself of a therapist, perhaps one who specialises in cognitive behavioral therapy (CBT).
Finally, if both your heart rate and your blood pressure are within normal parameters for the 'average' population your age and sex, then I would not fiddle with my dose of any medication. If you are still in those ranges with the newly reduced dose of metoprolol, then keep it there for now until you can consult a qualified expert on the subject of your heart health.
Again, whether or not you take metoprolol has nothing to do with your anxiety. Your anxiety is a manifestation of your uncertainty and fear about your bodily sensations or the information you take as veridical and diagnostic about your heart health and function, they being BP and HR. You should probably get affirmation from the medical community, and seek a therapist to help you to manage your anxiety....it does you no favors with a heart that is playing at arrythmia or rate control.
Good luck!
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2 ReactionsI feel for you and the anxiety you are going through. Anxiety is a tough problem and just as much as legitimate disease as a broken leg or cancer or whatever a may affect a human body. At least you understand that anxiety is a big part of your life. I went through a serious time with it when I was exposed to toxic mold in a newly purchased house. It looks years to clean my house and body and get a handle on the anxiety. Just this last week I came off a holler monitor that I had for 4 weeks. Since Jan 1st I have had a near told stream of PACs, PVCs, SVTs and throw in 2 episodes of A-fib to boot. Finally I get a monitor to prove all the crazy stuff that is making me feel terrible and then the 2 days after I returned the monitor it stops. Everything is good at least for now. But I am tired of it and will be talking to my EP in 3 weeks. Most of the time I was in sinus rhythm except for the 2 short A-fib episodes. Even though I was in sinus I was still very uncomfortable with my heart. And it my energy was not normal because I was having so many non stop stream of rhythm issues. From what I know about metoprolol is that you need to carefully come off it. It is not as hard as reducing opioids or Xanax but coming down too fast can cause heart stress. Also remember that mental stress can also cause palpitations.
I think a little help from a qualified mental help professional is something to seriously consider. After all you are faced with cardiac issues along with mental stress. I have had my metabolic panel done so I understand what kind of metabolizer I am of various drugs. That is helpful sometimes when understanding drug metabolism for you body type. It's an inexpensive test. I do not understand why everybody is not tested for the basic metabolic drug and genetic phenotypes. I wish you the best.