Calcium Channel Blockers: Because of significant inotropic and chronotropic effects in patients treated with beta-blockers and calcium channel blockers of the verapamil and diltiazem type, caution should be exercised in patients treated with these agents concomitantly.Peripheral Vascular Disease: Can aggravate symptoms of arterial insufficiency.Anaphylactic Reactions: Patients may be unresponsive to the usual doses of epinephrine used to treat allergic reaction.Thyrotoxicosis: Abrupt withdrawal in patients with thyrotoxicosis might precipitate a thyroid storm.Patients with Hepatic Impairment: (5.7).Diabetes and Hypoglycemia: May mask tachycardia occurring with hypoglycemia.Do not routinely withdraw chronic beta blocker therapy prior to surgery. Major Surgery: Avoid initiation of high-dose extended-release metoprolol in patients undergoing non-cardiac surgery because it has been associated with bradycardia, hypotension, stroke and death.Pheochromocytoma: If required, first initiate therapy with an alpha blocker.Bronchospastic Disease: Avoid beta blockers.Heart Failure: Worsening cardiac failure may occur.
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