Propranolol Discontinuation: Gradual Tapering Required
Propranolol must be gradually tapered over at least a few weeks rather than abruptly discontinued to prevent potentially serious withdrawal effects, including rebound hypertension, exacerbation of angina, and in severe cases, myocardial infarction or sudden death. 1
Rationale for Gradual Tapering
Abrupt discontinuation of propranolol can lead to:
- Rebound hypertension
- Exacerbation of angina pectoris
- Increased risk of myocardial infarction
- Enhanced beta-adrenergic sensitivity
- Tachycardia and arrhythmias
- Increased plasma catecholamines
The FDA label for propranolol explicitly warns that "when discontinuance of propranolol is planned, the dosage should be gradually reduced over at least a few weeks, and the patient should be cautioned against interruption or cessation of therapy without the physician's advice." 1
Recommended Tapering Protocol
The optimal tapering approach depends on the indication, dose, and duration of therapy:
Standard Tapering Approach
- Reduce the dose by approximately 25-30% every 1-2 weeks
- For example, if taking 80mg daily, reduce to 60mg daily for 1-2 weeks, then 40mg daily for 1-2 weeks, then 20mg daily for 1-2 weeks before stopping 2
For Higher Risk Patients
Patients with coronary artery disease, severe hypertension, or on higher doses should follow a more gradual taper:
- Reduce by smaller increments (e.g., 25% reduction)
- Maintain each dose level for 1-2 weeks
- Consider a prolonged small dose (30mg daily) for the final 2 weeks before complete withdrawal 3
Monitoring During Tapering
During the tapering process, monitor for:
- Increased heart rate
- Elevated blood pressure
- Return of symptoms (angina, hypertension)
- Signs of enhanced beta-adrenergic sensitivity (tremor, anxiety, sweating)
If withdrawal symptoms occur during tapering, the previous dose should be temporarily reinstated, followed by a more gradual taper. 2
Special Considerations
Angina Patients
Patients with angina are at particularly high risk during propranolol withdrawal. Studies have shown that within two weeks of abrupt discontinuation, serious complications including intermediate coronary syndrome, ventricular tachycardia, myocardial infarction, and sudden death can occur. 4
Hypertensive Patients
In hypertensive patients, a prolonged small-dose schedule (maintaining a low dose for 2 weeks before complete withdrawal) has been shown to prevent enhanced cardiac beta-adrenergic sensitivity and other adverse events. 3
Comparison with Other Beta-Blockers
While the withdrawal syndrome is well-documented with propranolol, other beta-blockers like atenolol may have a different withdrawal profile. However, the American College of Cardiology and American Heart Association recommend avoiding abrupt cessation of all beta-blockers. 5, 2
Conclusion
The evidence clearly demonstrates that propranolol should never be stopped abruptly. The safest approach is a gradual taper over several weeks, with the final stage involving a prolonged period at a low dose before complete discontinuation. This approach minimizes the risk of serious cardiovascular events and other withdrawal symptoms.