Drugs in this Class
Metoprolol Extended-Release Tablets (Metoprolol Succinate Extended-Release Tablets, Toprol-XL Extended-Release Tablets)
Bisoprolol (Zebeta)
Metoprolol Tablets (Lopressor Tablets, Metoprolol Tartrate Tablets)

Summarizing the Evidence

• Carvedilol (Coreg, Coreg CR) is a combined alpha and beta blocker that, while not a true beta blocker, works similarly to beta blockers and is also used for heart failure.
• Bisoprolol, metoprolol (immediate release), metoprolol ER (extended release), and carvedilol (immediate and controlled release) have been well studied and have been shown in clinical studies to reduce the rate of death and hospitalizations in individuals with moderate to severe heart failure.
• While other beta blockers have also been studied and have been shown to reduce the rate of death and hospitalizations in individuals with heart failure, these beta blockers do not have the wealth of good evidence behind them to support their use over bisoprolol, metoprolol ER (extended release), or carvedilol.
• Guidelines for the treatment of heart failure recommend beta blockers as a standard treatment for patients with stable heart failure to reduce death and other complications related to heart failure.
• Beta blockers are generally well tolerated with mild side effects. In the past, beta blockers were thought to be poorly tolerated compared to other drugs used to treat heart failure, however new studies have shown that they are better tolerated than previously thought, especially if started at very low doses and increased slowly over time. Common adverse effects of beta blockers include fatigue, dizziness, depression, low blood pressure and low pulse.
• Carvedilol has been recently studied in comparison to metoprolol ER (extended release) in the treatment of heart failure. These studies have shown that carvedilol may be better than metoprolol ER (extended release) at preventing death due to heart failure. An interesting note, one study has shown that people with heart failure who take carvedilol have less incidence of developing diabetes than in people with heart failure taking metoprolol oral (immediate release). While interesting, this needs confirmation with additional studies.
• Selective beta-blockers (like metoprolol and bisoprolol) may be safer than non-selective beta-blockers (like carvedilol) to use in individuals with decreased lung function (from conditions like asthma, bronchitis, emphysema). The non-selective beta-blockers can have effects on the lungs as well as the heart. The selective beta-blockers mainly affect the heart and only affect the lungs when given at very high doses.

Dosing and Administration

• Metoprolol ER (extended release), bisoprolol, and carvedilol CR (controlled release) are typically taken once daily. However, metoprolol (immediate release) and carvedilol (immediate release) are typically taken two to three times per day because they have a shorter duration of action. Due to the many medications that people with heart failure typically take, once daily dosing of beta-blockers has been found to have better compliance rates than twice daily dosing. The better compliance usually results in less emergency room visits and hospital admissions.

Generic Availability

• Metoprolol (immediate release), metoprolol ER (extended release), carvedilol (immediate release),and bisoprolol are currently available in generic formulation. Carvedilol CR (controlled release) currently does not have a generic equivalent and may be more expensive.

Drug Interactions

Some interactions between medications can be more severe than others. The best way for you to avoid harmful interactions is to tell your doctor and/or pharmacist what medications you are currently taking, including any over-the-counter products, vitamins, and herbals. For specific information on how the drugs interact and the severity of the interaction, please use our Drug Interactions Checker.

Side Effects

To view specific side effect information, please use our Side Effect Checker.

Additional Information

References

1. Anonymous. Randomised, placebo-controlled trial of carvedilol in patients with congestive heart failure due to ischaemic heart disease. Australia/New Zealand Heart Failure Research Collaborative Group. Lancet. 1997;349(9049):375-80.
2. Cardiosource (from the American College of Cardiology) [resource on World Wide Web]. URL: http//www.cardiosource.com. Available from Internet. Accessed 2000 Sept 19, June 16, 2006, April 9, 2008.
3. Bristow MR, Gilbert EM, Abraham WT et al. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure. MOCHA Investigators. Circulation. 1996;94(11):2807-16.
4. Membership of the Advisory Council to Improve Outcomes Nationwide in Heart Failure. Consensus Recommendations for the Management of Chronic Heart Failure. Am J Cardiol. 1999;83(2A):1A-38A.
5. Packer M, Bristow MR, Cohn JN et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. NEJM. 1996;334(21):1349-55.
6. Packer M, Colucci WS, Sackner-Bernstein JD et al. Double-blind, placebo-controlled study of the effects of carvedilol in patients with moderate to severe heart failure. The PRECISE Trial. Prospective Randomized Evaluation of Carvedilol on Symptoms and Exercise. Circulation. 1996;94(11):2793-9.
7. Packer M, Coats AJS, Fowler MB et al. Effect of carvedilol on survival in severe chronic heart failure. (The COPERNICUS Trial.) N Engl J Med. 2001;344:1651-8.
8. Anonymous. Effects of metoprolol CR in patients with ischemic and dilated cardiomyopathy: The Randomized Evaluation of Strategies for Left Ventricular Dysfunction Pilot Study. Circulation 2000;101:378-384.
9. Hjalmarson A, Goldstein S, Fagerberg B et al. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group. JAMA. 2000;283(10):1295-302.
10. Tsuyuki RT, Yusuf S, Rouleau JL et al. Combination neurohormonal blockade with ACE inhibitors, angiotensin II antagonists and beta-blockers in patients with congestive heart failure: design of the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) Pilot Study. Can J Cardiol. 1997;13(12):1166-74.
11. Anonymous. 3-year follow-up of patients randomised in the metoprolol in dilated cardiomyopathy trial. The Metoprolol in Dilated Cardiomyopathy (MDC) Trial Study Group. Lancet. 1998;351(9110):1180-1.
12. Waagstein F, Bristow MR, Swedberg K et al. Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Lancet. 1993;342:1441-46.
13. Anonymous. A randomized trial of beta-blockade in heart failure: The Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation. 1994;90(4):1765-1773.
14. Anonymous. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353:9-13.
15. Gilbert EM, Abraham WT, Olsen S et al. Congestive heart failure/myocardial disease: Comparative hemodynamic, left ventricular functional, and antiadrenergic effects of chronic treatment with metorpolol versus carvedilol in the failing heart. Circulation. 1996;94(11):2817-2825.
16. Kukin ML, Kalman J, Charney RH et al. Prospective, randomized comparison of effect of long-term treatment with metoprolol or carvedilol on symptoms, exercise, ejection fraction, and oxidative stress in heart failure. Circulation. 1999;99:2645-2651.
17. Sanderson JE, Chan SKW, Yip G et al. Beta-blockade in heart failure: a comparison of carvedilol with metoprolol. J Am Coll Cardiol. 1999;34(5):1522-1528.
18. Johnson JA, Parker RB, Patterson JH. Heart Failure. In DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York: McGraw-Hill; 2005. p. 219-260.
19. Remme WJ, Torp-Pedersen C, Poole-Wilson PA, et al. Carvedilol Protects Better Against Vascular Events Than Metoprolol in Heart Failure: Results from COMET. Journal of American College of Cardiology 2007 Mar 6; 49(9): 963-71.
20. Mrdovic IB, Savic RM, Perunicic JP, et al. Randomized active-controlled study comparing effects of treatment with carvedilol versus metoprolol in patients with left ventricular dysfunction after acute myocardial infarction. American Heart Journal 2007 July; 154(1): 116-22.
21. Cleland JGF, Charlesworth A, Lubsen J, et al. A Comparison of the Effects of Carvedilol and Metoprolol on Well-Being, Morbidity, and Mortality (the "Patient Journey") in Patients With Heart Failure: A Report from the Carvedilol or Metoprolol European Trial (COMET). Journal of the American College of Cardiology 2006 April 18; 47(8): 1603-11.
22. Albert NM. Switching to Once-Daily Evidence-Based beta-blockers in Patients With Systolic Heart Failure or Left Ventricular Dysfunction After Myocardial Infarction. CriticalCareNurse 2007;27(6): 62-72.
23. Torp-Pedersen C, Metra M, Charlesworth A, et. al. Effects of metoprolol and carvedilol on pre-existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET). Heart 2007;93:968-973.

Last Updated: April 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It should not be construed to indicate that the use of the product is safe, appropriate, or effective for you. Consult your healthcare professional before taking any medication.

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