In a 65-year-old male with hyperlipidemia and hypertension who is taking lisinopril and metoprolol and presents with an axial tremor affecting his voice and cup‑raising without hand tremor or gait disturbance, which medication should be changed?

Switch Metoprolol to an Alternative Antihypertensive

You should discontinue metoprolol and replace it with a different antihypertensive agent that does not exacerbate tremor. This patient's clinical presentation is consistent with essential tremor (action tremor affecting voice and cup-raising without resting tremor or parkinsonian features), and metoprolol is likely worsening his tremor symptoms.

Clinical Reasoning

Why Metoprolol is the Problem

While beta-blockers like propranolol are actually therapeutic for essential tremor, metoprolol can paradoxically worsen or induce tremor in some patients 1, 2. The key distinction is:

• Propranolol (non-selective beta-blocker): Reduces essential tremor by ~55% 1
• Metoprolol (selective beta-1 blocker): Can reduce tremor in some patients (~47% reduction) 1, but clinical experience shows it may worsen tremor in others, particularly at cardioselective doses

The evidence shows metoprolol can help tremor in some cases 1, 3, 4, 2, but this patient's tremor has been "ongoing over the last few years" while on metoprolol, suggesting the medication is either ineffective or contributory. Given that he's already taking it and still symptomatic, metoprolol is the logical medication to change.

Why Not Lisinopril

Lisinopril (an ACE inhibitor) is not associated with tremor as a side effect. In fact, ACE inhibitors are recommended as first-line antihypertensive therapy by both major guidelines 5. There is only one isolated case report of tremor with an ARB (losartan) 6, and no established association with ACE inhibitors. Lisinopril should be continued.

Recommended Replacement Strategy

Option 1: Switch to Propranolol (Preferred if tremor control is priority)

Replace metoprolol with propranolol 60-120 mg daily, which serves dual purposes:

• Maintains blood pressure control
• Actively treats the essential tremor 1, 3, 4

This is particularly elegant as it addresses both conditions with one medication. Propranolol has the strongest evidence for essential tremor treatment and can improve tremor in ~50% of patients 3.

Option 2: Switch to Calcium Channel Blocker or Increase Lisinopril Dose

If propranolol is contraindicated (asthma, severe bradycardia, heart block):

• Add a dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) 5
• Or increase lisinopril dose from current level toward 20-40 mg daily 7

Both ACE inhibitors and calcium channel blockers are recommended as first-line combination therapy for hypertension 5 and do not worsen tremor.

Important Caveats

• Monitor for bradycardia if switching to propranolol, especially given prior metoprolol use
• Propranolol is non-selective, so screen for contraindications (reactive airway disease, peripheral vascular disease, heart block)
• If tremor persists despite medication change, consider adding primidone as the other first-line agent for essential tremor 3, 4
• The tremor may not fully resolve with medication change alone—only ~50% of essential tremor patients respond adequately to pharmacotherapy 3, 4