Can discontinuing metoprolol (beta blocker) improve symptoms of Peyronie's disease in a middle-aged male patient with a history of hypertension (high blood pressure)?

Discontinuing Metoprolol for Peyronie's Disease

Discontinuing metoprolol is a reasonable initial step for patients with Peyronie's disease who are taking this beta-blocker, as beta-blockers have been associated with the development of Peyronie's disease, though the evidence for improvement after discontinuation is limited to case reports.

Evidence Linking Beta-Blockers to Peyronie's Disease

The association between beta-blockers and Peyronie's disease is documented but rare:

• Beta-blockers, including metoprolol, are listed as a potential drug-induced cause of Peyronie's disease in the most recent European Association of Urology guidelines 1
• A case report documented both Peyronie's disease and a lupus-like syndrome developing six months after metoprolol initiation, with improvement in symptoms and signs following drug withdrawal 2
• The mechanism may involve an autoimmune fibrotic process similar to that seen with practolol and other beta-blockers 2
• Historical literature notes that beta-blockers can sometimes result in Peyronie's disease, likely through nonspecific inflammatory mechanisms 3

Clinical Decision Algorithm

Step 1: Assess cardiovascular necessity of metoprolol

• If metoprolol is being used for heart failure with reduced ejection fraction, it should be continued as it provides mortality benefit 1
• If used for hypertension alone, alternative antihypertensive agents can be substituted 1
• If used for coronary artery disease without heart failure, consider switching to an alternative beta-blocker or different antihypertensive class 1

Step 2: If discontinuation is appropriate

• Never abruptly discontinue beta-blockers, as this is potentially harmful and can precipitate cardiovascular events 1
• Taper metoprolol gradually over 1-2 weeks while monitoring blood pressure and heart rate 1
• Substitute with alternative antihypertensive agents that do not cause sexual dysfunction, such as ACE inhibitors, ARBs, or calcium channel blockers (avoiding non-dihydropyridines if heart failure is present) 1

Step 3: Monitor for Peyronie's disease progression

• Reassess penile curvature, plaque characteristics, and pain at 3-6 months after metoprolol discontinuation 1
• Document whether the disease stabilizes or improves, though spontaneous resolution occurs in approximately one-third of cases regardless of intervention 1, 4

Important Caveats

The evidence for improvement after beta-blocker discontinuation is extremely weak:

• Only one case report 2 documents improvement after metoprolol withdrawal
• No controlled studies have evaluated whether discontinuing beta-blockers improves established Peyronie's disease 1
• The natural history of Peyronie's disease includes spontaneous resolution in many cases, making causality difficult to establish 4

Cardiovascular risk must take priority:

• In patients with heart failure, carvedilol or bisoprolol provide proven mortality benefit and should not be discontinued for Peyronie's disease alone 1
• Abrupt beta-blocker cessation increases risk of myocardial infarction and arrhythmias 1

Alternative Management if Metoprolol Cannot Be Discontinued

If cardiovascular indications mandate continued beta-blocker therapy:

• Consider intralesional collagenase clostridium histolyticum (Xiaflex) for patients with curvature 30-90° and intact erectile function (Moderate Recommendation, Grade B evidence) 1, 5
• Intralesional interferon α-2b may be offered for stable disease with documented efficacy in reducing curvature (13.5° vs 4.5° placebo), plaque size, and pain 1
• Surgery remains the definitive treatment for severe deformity interfering with intercourse after 12 months of conservative management 1, 3, 6

The decision to discontinue metoprolol should be made collaboratively with cardiology, weighing the uncertain benefit for Peyronie's disease against the established cardiovascular risks of inappropriate beta-blocker cessation.