How to rapidly taper and discontinue guanfacine (Intuniv) Extended Release (ER) 2 milligrams in an 8-year-old child experiencing severe aggression, as prescribed by a psychiatrist?

From the Guidelines

To taper and stop guanfacine ER 2 mg quickly in an 8-year-old child showing aggression, I recommend a 1-week taper rather than abrupt discontinuation, as suggested by the most recent guidelines 1. This approach is necessary to balance the need for rapid discontinuation with safety concerns, as guanfacine is an alpha-2 adrenergic agonist that affects norepinephrine regulation in the brain and cardiovascular system. The recommended tapering schedule is to reduce the dose to 1 mg daily for 3-4 days, then to 0.5 mg daily for 3-4 days before stopping completely. Some key points to consider during the tapering process include:

• Monitoring for potential withdrawal symptoms, including rebound hypertension, tachycardia, nervousness, headache, and worsening behavior 1
• Regular monitoring of blood pressure and heart rate, especially if the child has been on guanfacine for several months 1
• Considering hospitalization or close monitoring during the taper period if the child's aggression is severe and immediate discontinuation seems necessary
• Contacting the psychiatrist immediately to reassess the plan if symptoms worsen during the taper It's also important to note that rebound hypertension after abrupt guanfacine discontinuation has been observed, making a tapered approach essential 1. Additionally, the American Academy of Child and Adolescent Psychiatry suggests that prescribers should taper medication slowly to avoid withdrawal symptoms or rebound worsening of symptoms 1. However, the most recent and highest quality study 1 provides the most relevant guidance for tapering guanfacine ER in this scenario.

From the FDA Drug Label

Patients should be advised not to discontinue therapy abruptly. Further, if guanfacine is to be discontinued in such patients, careful tapering of the dosage may be necessary in order to avoid rebound phenomena (see Reboundabove)

To taper and stop guanfacine ER 2 mg in an 8-year-old kid, careful tapering of the dosage is necessary to avoid rebound phenomena.

• The drug label does not provide a specific tapering schedule, so a conservative approach should be taken.
• It is recommended to consult the prescribing psychiatrist to determine the best course of action for tapering and stopping the medication.
• Given the patient's history of aggression on guanfacine, close monitoring is necessary during the tapering process to ensure the patient's safety and adjust the tapering schedule as needed 2.

From the Research

Tapering and Stopping Guanfacine ER in an 8-Year-Old Kid

• The decision to taper and stop guanfacine ER in an 8-year-old kid who has been aggressive on the medication should be made by a psychiatrist, taking into account the individual child's needs and medical history.
• According to a study published in 2007 3, guanfacine ER can be abruptly discontinued without significant increases in systolic blood pressure (SBP) or diastolic blood pressure (DBP) in healthy young adults.
• However, the study also found that the taper-down group had a similar decrease in SBP and DBP compared to the abrupt-cessation group, suggesting that tapering may not be necessary in all cases.
• Another study published in 2023 4 found that guanfacine is safe and effective for treating attention-deficit/hyperactivity disorder (ADHD) in children, with no serious adverse events reported.
• A case series published in 2025 5 suggested that guanfacine may be effective in managing behavioral disturbances in patients with dementia, including irritability, agitation, and anxiety.
• A systematic literature review published in 2019 6 found that guanfacine had an effect on autism symptoms, oppositional defiant symptoms, and possibly on tics in children and adolescents with ADHD.
• An older study published in 1980 7 found that guanfacine is an effective antihypertensive drug, but that abrupt withdrawal can lead to an increase in blood pressure over a 2-4 day period.

Potential Tapering Schedule

• Based on the study published in 2007 3, a potential tapering schedule for guanfacine ER could be:

• 3 mg on days 1-4
• 2 mg on days 5-8
• 1 mg on days 9-12
• placebo on days 13-16

• However, it is essential to note that this schedule was used in a study with healthy young adults, and the optimal tapering schedule for an 8-year-old kid may be different.
• The psychiatrist should closely monitor the child's behavior and adjust the tapering schedule as needed to minimize potential adverse effects.