Does metoprolol help with tremor?

Does Metoprolol Help with Tremor?

Metoprolol can help with tremor, but it is significantly less effective than propranolol and should only be considered as a second-line alternative when propranolol is contraindicated, particularly in patients with asthma or reactive airway disease. 1, 2

Evidence for Metoprolol's Efficacy

Essential Tremor Treatment

• Propranolol remains the gold standard for essential tremor, having been used successfully for over 40 years with established efficacy in up to 70% of patients. 1, 3

• Metoprolol shows modest benefit but is consistently inferior to propranolol across multiple studies:

  • In single-dose studies, metoprolol reduced tremor intensity by 32% compared to propranolol's 41.3% reduction. 2
  • Only 1 of 24 patients reported subjective benefit with metoprolol versus 15 patients with propranolol. 2
  • During prolonged administration (4 weeks), metoprolol's effectiveness was not significantly different from placebo, while propranolol remained superior at both 120 mg and 240 mg daily doses. 4

When to Consider Metoprolol

• Primary indication: contraindication to propranolol, specifically in patients with:

  • Asthma or reactive airway disease 1, 5
  • Chronic obstructive pulmonary disease with bronchospasm 1

• Metoprolol successfully reduced tremor in 3 patients with asthma who had experienced respiratory distress with propranolol. 5

• Individual response patterns exist: patients who respond to propranolol may also respond to metoprolol, but those who don't respond to propranolol typically won't respond to metoprolol either. 5

Clinical Algorithm for Beta-Blocker Selection in Tremor

First-Line Treatment

• Start with propranolol (non-selective beta-blocker) unless contraindicated. 1, 3
• Propranolol works by blocking peripheral beta-2 receptors in skeletal muscle, reducing tremor amplitude. 3, 6

Second-Line: When to Switch to Metoprolol

• Switch to metoprolol only if:
  • Patient has asthma or bronchospastic pulmonary disease 1, 5
  • Patient experiences intolerable side effects from propranolol 7
  • Propranolol is otherwise contraindicated 1

Dosing Considerations

• Metoprolol doses studied: 150-300 mg daily 4
• Propranolol doses: 120-240 mg daily 4
• Higher doses of metoprolol may lose cardioselectivity, potentially explaining any tremor reduction through beta-2 blockade. 6

Important Precautions

Contraindications for Both Drugs

• AV block greater than first degree or SA node dysfunction (without pacemaker) 1
• Decompensated systolic heart failure 1
• Severe hypotension 1
• Cardiogenic shock 1

Specific Cautions

• Diabetes: Both drugs may mask hypoglycemia symptoms; use with caution. 3, 8
• Never abruptly discontinue after regular use due to risk of rebound symptoms. 3, 8
• Common side effects include bradycardia, hypotension, fatigue, and cold extremities. 3, 8

Other Tremor Contexts

Thyrotoxicosis and Hyperthyroidism

• Propranolol is the preferred beta-blocker for treating tremor associated with excess thyroid hormone, as it also inhibits peripheral T4 to T3 conversion. 1
• No specific evidence supports metoprolol superiority in this context. 1

Performance Anxiety and Physiologic Tremor

• Propranolol effectively reduces physiologic tremor during performance anxiety by blocking peripheral adrenaline effects. 3
• The American College of Surgeons recommends propranolol for surgeons experiencing procedural tremor. 3
• No guideline-level evidence supports metoprolol for performance-related tremor. 3

Bottom Line

Use propranolol first for any tremor indication unless the patient has asthma, COPD with bronchospasm, or cannot tolerate propranolol. 1, 7, 5 Metoprolol offers a reasonable but less effective alternative in these specific circumstances, with approximately 50% of patients experiencing some tremor reduction. 7, 5 If neither propranolol nor metoprolol provides adequate control, consider combination therapy with primidone or alternative agents like gabapentin or topiramate. 7