Beta-Blocker Equivalency
Convert between metoprolol, carvedilol, bisoprolol, atenolol, propranolol, nebivolol, and labetalol with HF target-dose context.
- Switching a HFrEF patient between beta-blockers (e.g., carvedilol → metoprolol succinate at hospital transition)
- Estimating a sane starting dose when an outpatient agent isn't on the inpatient formulary
- Cross-mapping a home labetalol dose against a planned metoprolol IV order
- Equivalency is about β1 blockade, not blood pressure or HF benefit. Carvedilol and labetalol pull BP harder because of α-blockade; switching at "equivalent" β1 dose can leave the BP higher.
- In HFrEF, only four agents have mortality data. Carvedilol, metoprolol succinate, bisoprolol, and (in HFpEF/elderly) nebivolol. Switching from one of these to atenolol or labetalol on a "per mg" basis is not equivalent care.
- Metoprolol succinate vs tartrate. Total daily dose is roughly the same (e.g., 100 mg succinate ≈ 50 mg tartrate BID), but PK differs — succinate is once-daily; tartrate is BID with peak/trough variability.
- Renal vs hepatic clearance matters. Atenolol and bisoprolol need dose-reduction in CKD; metoprolol and carvedilol are hepatically metabolized.
- Selectivity matters in asthma, COPD, hyperthyroidism, migraine. Switching from a β1-selective agent to a non-selective one isn't trivial.
Beta-blocker rotations are routine on the wards — formulary swaps, transitions of care, dose simplification. The mistake is treating this as a simple converter when in fact every agent has a different receptor profile, half-life, and indication base. The numbers help; the caveats matter as much.
| Drug | Daily dose | Schedule |
|---|---|---|
| Metoprolol succinate (XL) | 100mg/day | daily |
| Metoprolol tartrate (IR) | 100mg/day | BID |
| Carvedilol | 25mg/day | BID |
| Bisoprolol | 5mg/day | daily |
| Atenolol | 50mg/day | daily |
| Propranolol | 80mg/day | TID–QID (IR) |
| Nebivolol | 5mg/day | daily |
| Labetalol | 200mg/day | BID |
Target dose for HFrEF
Guideline-directed target for Metoprolol succinate (XL): 200 mg/day (MERIT-HF target). Your input is 50% of target.
Cross-class equivalency is approximate
- Carvedilol and labetalol have α-blockade — they lower BP more than a pure β1 conversion suggests.
- Receptor selectivity (β1 vs non-selective) matters in asthma, hyperthyroidism, and migraine.
- Metoprolol succinate (XL) is once-daily; tartrate is BID — total daily dose is roughly equivalent but PK is not.
- For HFrEF, only the four trial-validated agents (carvedilol, metoprolol succinate, bisoprolol, nebivolol in HFpEF/elderly) carry mortality benefit.
Frequently asked
What is the equivalent dose of carvedilol to metoprolol succinate?
A common conversion is 25 mg/day carvedilol ≈ 100 mg/day metoprolol succinate (so 12.5 mg BID carvedilol ≈ 100 mg succinate daily). This is a β1-equivalent estimate — actual blood pressure response will differ because carvedilol also blocks α1 receptors.
Is metoprolol tartrate the same as metoprolol succinate at the same dose?
The total daily dose is roughly equivalent (50 mg BID tartrate ≈ 100 mg daily succinate), but the pharmacokinetics differ. Tartrate is immediate-release and dosed BID; succinate is extended-release and dosed once daily. Substituting them mg-for-mg without adjusting the schedule produces peak / trough swings that the once-daily formulation was designed to avoid.
Can I switch from labetalol to metoprolol at home?
You can, but the BP often rises after the switch because labetalol has α-blockade that metoprolol does not. A common conversion is labetalol 200 mg/day ≈ metoprolol 100 mg/day, but in practice clinicians typically titrate up the metoprolol over several days while monitoring BP, and may add a separate agent (amlodipine, hydrochlorothiazide) to replace the lost α-effect.
Which beta-blockers are evidence-based for heart failure?
Four agents have mortality benefit in HFrEF: carvedilol (COPERNICUS, CAPRICORN), metoprolol succinate (MERIT-HF), bisoprolol (CIBIS-II), and nebivolol (SENIORS, in elderly HFpEF/HFrEF). Atenolol, propranolol, and labetalol do not carry equivalent evidence and should not be assumed to provide HF benefit when substituted at "equivalent" doses.
What's the target dose for beta-blockers in HFrEF?
Trial target doses: carvedilol 25 mg BID (50 mg BID if >85 kg), metoprolol succinate 200 mg/day, bisoprolol 10 mg/day. The mortality benefit was seen at these doses; lower doses are reasonable as starting points but should be uptitrated as tolerated.