Can Diamox (acetazolamide) be stopped immediately in a 74-year-old male who has been taking it daily for 10 years to prevent morning shortness of breath (SOB) with Continuous Positive Airway Pressure (CPAP), or does it need to be weaned?

Acetazolamide (Diamox) Discontinuation in a 74-Year-Old Male

Acetazolamide (Diamox) can be stopped immediately in this 74-year-old male patient who has been taking it for 10 years to prevent morning shortness of breath with CPAP, especially since it is causing headaches.

Rationale for Immediate Discontinuation

Acetazolamide (Diamox) does not require tapering when discontinuing therapy for the following reasons:

• Unlike medications that act on the central nervous system (such as psychotropic drugs, dopaminergic drugs, or opioids), acetazolamide is not known to cause significant withdrawal symptoms when stopped abruptly 1.

• The guidelines for medication discontinuation indicate that gradual tapering is primarily necessary for drugs that act on the central nervous system, beta-blockers, corticosteroids, and proton-pump inhibitors 1. Acetazolamide does not fall into these categories.

• Acetazolamide is a carbonic anhydrase inhibitor that functions as a chloride-regaining diuretic 2, and its discontinuation does not typically lead to rebound effects that would necessitate tapering.

Clinical Considerations

Current Use and Side Effects

• The patient has been using acetazolamide to prevent morning shortness of breath with CPAP therapy
• He is experiencing headaches, which is a known side effect of acetazolamide
• After 10 years of use, the risk-benefit ratio should be reassessed, especially given the presence of side effects

Monitoring After Discontinuation

After stopping acetazolamide, monitor for:

1. Changes in respiratory status, particularly morning shortness of breath
2. Resolution of headaches (should improve within days of discontinuation)
3. Need for CPAP adjustment, as acetazolamide may have been affecting respiratory drive

Alternative Management Strategies

If morning shortness of breath returns after discontinuing acetazolamide, consider:

• Optimizing CPAP settings with possible pressure adjustments
• Ensuring proper mask fit and addressing any leak issues
• Evaluating for other causes of morning shortness of breath
• Considering alternative medications with fewer side effects if pharmacological intervention is still needed

Special Considerations for Older Adults

In older adults (74 years), medication reduction is often beneficial:

• Reducing polypharmacy decreases the risk of drug interactions and adverse effects 3
• Careful monitoring of oral intake and symptoms is warranted after medication changes 3
• Quality of life should be prioritized, and the resolution of headaches may significantly improve the patient's well-being

Potential Pitfalls

• Monitor for return of morning shortness of breath, which may indicate the need to reconsider management strategy
• Be aware that acetazolamide has been shown to reduce residual sleep apnea in patients with high loop gain sleep apnea 4, so its discontinuation might affect sleep quality
• If the patient was using acetazolamide for its effects on acid-base balance, monitor for changes in respiratory status that might indicate worsening hypercapnia

In conclusion, acetazolamide can be safely discontinued immediately without tapering in this patient. The resolution of headaches will likely improve his quality of life, and any return of respiratory symptoms can be addressed through optimization of CPAP therapy or consideration of alternative management strategies.