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Case Report: Metoprolol-Induced Arthralgia

• By Saba Ziaee, MD, & Zineb Aouhab, MD

Various drugs are known to cause musculoskeletal symptoms, such as arthralgias, myalgias, drug-induced lupus and serum sickness.1 In the rheumatology world, the most commonly recognized drugs that can cause musculoskeletal symptoms are hydralazine, minocycline, fluoroquinolones and, recently, the dipeptidyl peptidase 4 (DPP-4) inhibitor class of medications. Although beta blockers also have a noted side effect of arthralgias, as listed on the product label, there is lack of literature and awareness that this class of medications can cause arthralgias, as well as elevated anti-nuclear antibodies.2

In 1986, Sills documented five cases of self-reported metoprolol-induced arthralgias through the U.S. Food and Drug Administration’s spontaneous reporting system, all of which resolved within days of discontinuing the medication (see Table 1).3 Historically, practolol caused a more severe multisystem immunologic syndrome; however, metoprolol was also found to produce a range of disease severity, from simple arthralgias to multisystem disease.4

Case Report

A 59-year-old female presented to the primary care doctor due to six to twelve months of polyarthralgias. Pain was migratory, primarily in the metatarsal joints of both feet, lateral hips and wrists. She had about 30 minutes of morning stiffness in the toes, and fingers of the right hand and low back. Pain improved with non-steroidal anti-inflammatory drugs (NSAIDs), but did not resolve.

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Her prior history was significant for fluoroquinolone-induced arthralgias two years earlier after urinary tract infection treatment, as well as plantar fasciitis and trochanteric bursitis, for which she had multiple corticosteroid injections.

The patient had taken levothyroxine and sertraline for several years. She had changed from triamterene-hydrochlorothiazide to metoprolol for blood pressure control about a year earlier.

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Her symptoms did not improve with exercises or NSAIDs. Following a podiatry referral, the patient went to a rheumatologist.

The examination was significant for a positive, right Finkelstein maneuver, bilateral first MTP tenderness without swelling or erythema, bilateral greater trochanteric bursa tenderness, and a positive Patrick’s maneuver bilaterally.

A prior pelvic X-ray (see Figure 1) had shown sacroiliac joint osteoarthritis and enthesopathy, which, along with the examination findings, prompted the rheumatologist to order a pelvic MRI.

Table 1: 5 Cases of Self-Reported Metoprolol-Induced Arthralgias4

(click for larger image) Table 1: Five Cases of Self-Reported Metoprolol-Induced Arthralgias4

Further workup, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factory (RF), HLA B27, an ultrasound of the hand and wrist and the pelvic MRI were negative.

Metoprolol was discontinued upon the patient’s request while she was undergoing the workup, which resulted in complete resolution of her arthralgias within two to three days after drug cessation.

Discussion

A pelvic X-ray had shown sacroiliac joint osteoarthritis and enthesopathy.

A pelvic X-ray had shown sacroiliac joint osteoarthritis and enthesopathy.

Comments

  1. I started Toprol in January 2017, I noticed some bone pain in pelvis and hips. I also had a lot of stiffness. I also was told my vitamin d level was low and calcium elevated. I had surgery for hyperparathyroidism. About 3 months ago started having severe stiffness and pain in feet. Carol

    Reply

    • I AM EXPERIENCING PAIN IN THE JOINTS AT THE BASE OF BOTH THUMBS INCLUDING SOME SLIGHT TINGLING AT TIP OF MY THUMB FOR FIVE MONTHS, I HAVE BEEN TAKING A QUARTER OF A TABLET OF METROPOL FOR TWO YEARS FOR BLOOD PRESSURE, HEALTH REASONS, INTERESTINGLY, THE JOINTS ARE NOT SWOLLEN AND THE PAIN CAN SHIFT FROM ONE THUMB TO THE OTHER OR LESS IN ONE AND MORE IN THE OTHER. IT SEEMS TO SHIFT AROUND. THE PAIN IS HOWEVER IS NOT TOO DEBILITATING ; ITS MORE ANNOYING THAN ANYTHING, I CAN LIVE WITH IT AND CAN STILL WEILD A TENNIS RAQUET, A WEEK AGO I STOPPED TAKING A LOW DOSE OF METROPOL (1/4 OF A TABLET) AND HAVE NOTICED A MARKED IMPROVEMENT WHICH I HOPE WILL CONTINUE. IN FACT, THE ONLY REASON I LOOKED THIS SITE UP WAS SIMPLY BECAUSE I WANTED TO SEE IF THERE MIGHT POSSIBLY BE A LINK BETWEEN THE TWO, GIVEN MY BELIEF THAT MY THUMB JOINT PAIN HAD EASED SINCE CEASING MY BETA BLOCKER MEDICATION. YOUR SITE WOULD SEEM TO CONFIRM THAT THERE MIGHT WELL BE A LINK . SO THANKS FOR PUBLISHING THIS LITTLE KNOWN RESEARCH. HOPEFULLY WE ARE ON TO SOMETHING THAT CAN HELP OTHERS.

      IAN BROWN
      -62 YEARS –
      LIVING TOOWOOMBA QLD AUSTRALIA .

      Reply

  2. I have had arthritis in my right knee for years and never had any pain.
    After having a SCAD heart attack in January, and again in February doctor put me on Metoprolol. Ever since then my knee pain is so bad I have not been able to walk without crutches.

    I am just looking for a link here. If this is it I really want off this medication.

    Reply

    • Me too! I thought it was being placed on levoquin after surgery but now I’m wondering about the recent metoprolol that I was also prescribed for rapid heart rate. I’ve missed my daily doses of metoprolol for the past 2 days and I feel so much better! Interesting! I can walk again without pain!

      Reply

  3. I’ve been taking Metoprolol for three months to keep my blood pressure in check. (53 years old) I started at 100 to 50 n now 25 mg. I stopped yesterday. Im having severe pain in my feet, ankles, knees, elbows, hands ; pain jumps around my Joints. My feet n hands feel swollen but aren’t. Very hard to walk at times, especially in the mornings. My feet feel like walking on a million needles. So debilitating!
    Taking Ibuprofen and leftover pain meds to relieve my symptoms until this nasty drug leaves my system. A Hot Jacuzzi made it worse !!

    Reply

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