Metoprolol with Lidocaine Interaction Details

Brand Names Associated with Metoprolol

Medical Content Editor Dr. Brian Staiger, PharmD
Last updated Nov 05, 2023

Interaction Effect

Lidocaine toxicity (anxiety, myocardial depression, cardiac arrest)

Interaction Summary

Propranolol, metoprolol, and nadolol may increase lidocaine levels by 20% to 30%.

Severity

Major

Onset

Delayed

Evidence

Probable

How To Manage Interaction

With concurrent beta blocker therapy, monitor lidocaine levels more closely (at least every 24 hours) and adjust lidocaine infusion rates appropriately.

Mechanism Of Interaction

Decreased lidocaine metabolism

Literature Reports

A) Concomitant lidocaine and beta blocker therapy may reduce the clearance of lidocaine from plasma. This effect may be attributed to beta blocker-induced reduction in cardiac output and hepatic blood flow, and inhibition of hepatic microsomal enzymes. A 30% increase in mean steady-state concentrations of lidocaine has been observed during concomitant propranolol therapy. Propranolol, metoprolol, and nadolol have been reported to reduce lidocaine clearance by 15% to 45%. This difference is of clinical significance and the lidocaine dosage should be adjusted. This effect will be additive to the accumulation seen during continuous lidocaine infusions. Additionally, the negative inotropic effect of propranolol, and possibly other beta blockers, may be enhanced by lidocaine .

B) Both nadolol and propranolol are reported to decrease lidocaine plasma clearance in healthy volunteers . Six patients received three separate 30-hour infusions of lidocaine 2 mg/min, one given alone, one given following 3 days of pretreatment with nadolol 160 mg PO daily, and one following 3 days of pretreatment with propranolol 80 mg PO Q8H. In addition to reductions in lidocaine plasma clearance, lidocaine plasma levels were increased by both drugs, and hepatic blood flow (determined by indocyanine green) decreased with nadolol (1275 to 902 mL/minute) and propranolol (1275 to 957 mL/minute). The hepatic extraction ratio for lidocaine was increased to a similar degree by each drug; lidocaine intrinsic clearance was not changed by either drug. These data suggest that both beta blockers can reduce lidocaine clearance by a reduction in hepatic blood flow, but not by inhibition of lidocaine metabolism.

C) A study presented 2 cases of lidocaine toxicity during concomitant administration of normal doses of propranolol and lidocaine. The first case was a 56-year-old woman receiving 40 mg of oral propranolol daily who was given a 50 mg bolus of lidocaine to control ventricular premature contractions. The patient was then placed on a lidocaine drip, and within 15 minutes reported lightheadedness and accentuated bradycardia, which led to sinus arrest. The second case involved a 40-year-old woman on 160 mg of oral propranolol daily who received a 100 mg bolus of lidocaine to control ventricular tachycardia. A continuous lidocaine infusion at a rate of 2 mg/minute was initiated, and after 3.5 hours, the patient became hysterical and combative. The infusion was discontinued, and the patient returned to a normal mental state within 15 minutes. The lidocaine infusion was resumed at 1 mg/minute with no difficulties .

Metoprolol Overview

• Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to treat chronic (long-term) angina (chest pain). Metoprolol is also used to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.

• High blood pressure is a common condition and when not treated, can cause damage to the brain, heart, blood vessels, kidneys and other parts of the body. Damage to these organs may cause heart disease, a heart attack, heart failure, stroke, kidney failure, loss of vision, and other problems. In addition to taking medication, making lifestyle changes will also help to control your blood pressure. These changes include eating a diet that is low in fat and salt, maintaining a healthy weight, exercising at least 30 minutes most days, not smoking, and using alcohol in moderation.

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Definitions

Severity Categories

Contraindicated

These drugs, generally, should not be used together simultaneously due to the high risk of severe adverse effects. Combining these medications can lead to dangerous health outcomes and should be strictly avoided unless otherwise instructed by your provider.

Major

This interaction could result in very serious and potentially life-threatening consequences. If you are taking this drug combination, it is very important to be under close medical supervision to minimize severe side effects and ensure your safety. It may be necessary to change a medication or dosage to prevent harm.

Moderate

This interaction has the potential to worsen your medical condition or alter the effectiveness of your treatment. It's important that you are monitored closely and you potentially may need to make adjustments in your treatment plan or drug dosage to maintain optimal health.

Minor

While this interaction is unlikely to cause significant problems, it could intensify side effects or reduce the effectiveness of one or both medications. Monitoring for changes in symptoms and your condition is recommended, and adjustments may be made if needed to manage any increased or more pronounced side effects.

Onset

Rapid: Onset of drug interaction typically occurs within 24 hours of co-administration.

Delayed: Onset of drug interaction typically occurs more than 24 hours after co-administration.

Evidence

Level of documentation of the interaction.

Established: The interaction is documented and substantiated in peer-reviewed medical literature.

Theoretical: This interaction is not fully supported by current medical evidence or well-documented sources, but it is based on known drug mechanisms, drug effects, and other relevant information.

How To Manage The Interaction

Provides a detailed discussion on how patients and clinicians can approach the identified drug interaction as well as offers guidance on what to expect and strategies to potentially mitigate the effects of the interaction. This may include recommendations on adjusting medication dosages, altering the timing of drug administration, or closely monitoring for specific symptoms.

It's important to note that all medical situations are unique, and management approaches should be tailored to individual circumstances. Patients should always consult their healthcare provider for personalized advice and guidance on managing drug interactions effectively.

Mechanism Of Interaction

The theorized or clinically determined reason (i.e., mechanism) why the drug-drug interaction occurs.

Disclaimer: The information provided on this page is for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare professional regarding your specific circumstances and medical conditions.

Where Does Our Information Come From?

Information for our drug interactions is compiled from several drug compendia, including:

• Gold Standard Drug Database
• Micromedex
• Lexicomp
• DrugBank

The prescribing information for each drug, as published on DailyMED, is also used. 

Individual drug-drug interaction detail pages contain references specific to that interaction. You can click on the reference number within brackets '[]' to see what reference was utilized.

The information posted is fact-checked by HelloPharmacist clinicians and reviewed quarterly.