Peripheral Vascular Disease: Can aggravate symptoms of arterial insufficiency ( 5.10).Anaphylactic Reactions: Patients may be unresponsive to the usual doses of epinephrine used to treat allergic reaction ( 5.9).Thyrotoxicosis: Abrupt withdrawal in patients with thyrotoxicosis might precipitate a thyroid storm ( 5.8).Patients with Hepatic Impairment: ( 5.7).Diabetes and Hypoglycemia: May mask tachycardia occurring with hypoglycemia ( 5.6).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.
