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BradycardiaEvaluate the need for atropineadrenergic-stimulating drugs or pacemaker to treat bradycardia and conduction disorders.

If you do not understand the instructions on the packask your doctor or pharmacist for help.

The following adverse reactions have been identified during post-approval use of TOPROL-XL or immediate-release metoprololBecause these reactions are reported voluntarily from a population of uncertain sizeit is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

In manabsorption of metoprolol is rapid and completePlasma levels following oral administration of conventional metoprolol tabletshoweverapproximate 50of levels following intravenous administrationindicating about 50first-pass metabolismMetoprolol crosses the bloodbrain barrier and has been reported in the CSF in a concentration 78of the simultaneous plasma concentration.

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Dosage must be individualized and closely monitored during up-titrationPrior to initiation of TOPROL-XLstabilize the dose of other heart failure drug therapyThe recommended starting dose of TOPROL-XL is 25 mg once daily for two weeks in patients with NYHA Class II heart failure and 12.5 mg once daily in patients with more severe heart failureDouble the dose every two weeks to the highest dosage level tolerated by the patient or up to 200 mg of TOPROL-XLInitial difficulty with titration should not preclude later attempts to introduce TOPROL-XLIf patients experience symptomatic bradycardiareduce the dose of TOPROL-XLIf transient worsening of heart failure occursconsider treating with increased doses of diureticslowering the dose of TOPROL-XL or temporarily discontinuing itThe dose of TOPROL-XL should not be increased until symptoms of worsening heart failure have been stabilized.

If you miss a dosetake it as soon as you rememberIf it is near the time of the next doseskip themissed doseTake your next dose at the regular timeDo not double the dose to catch up.

TOPROL-XL is contraindicated in severe bradycardiasecond or third degree heart blockcardiogenic shockdecompensated cardiac failuresick sinus syndromeunless a permanent pacemaker is in placeand in patients who are hypersensitive to any component of this product.

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