What to do if a patient develops tremor after stopping guanfacine (Intuniv)?

Managing Tremor After Guanfacine Discontinuation

When a patient develops tremor after stopping guanfacine, gradual tapering rather than abrupt discontinuation is strongly recommended to prevent withdrawal symptoms including tremor.

Understanding Guanfacine Withdrawal

Guanfacine is an alpha-2 agonist used for conditions like ADHD and hypertension. According to the European Society of Cardiology, central acting antihypertensive drugs like guanfacine may cause withdrawal syndrome when suddenly discontinued 1. Unlike some other medications in its class, guanfacine has a longer duration of action and plasma half-life, which can affect withdrawal symptoms.

Mechanism of Withdrawal Tremor

Tremor following guanfacine discontinuation likely occurs due to:

• Rebound sympathetic nervous system activity
• Increased plasma noradrenaline levels that may exceed pretreatment levels 2
• Sudden changes in central alpha-2 adrenergic tone

Management Algorithm

Immediate Actions:

1. Reinstitute guanfacine at the previous effective dose

   • This quickly stabilizes symptoms in most cases
   • Addresses the underlying cause of the withdrawal syndrome

2. Implement proper tapering schedule:

   • Reduce dose by approximately 25% every 3-7 days
   • Typical tapering schedule: 1-2 weeks for patients on lower doses, 2-4 weeks for higher doses
   • Monitor blood pressure during tapering process

3. Consider symptomatic treatment for tremor if severe:

   • Propranolol (10-40mg) can be used short-term to manage tremor symptoms 3, 4
   • Benzodiazepines may be considered for short-term use if anxiety is exacerbating tremor 4

Monitoring During Tapering:

• Blood pressure and heart rate (guanfacine withdrawal can cause BP changes)
• Tremor severity
• Other potential withdrawal symptoms (headache, agitation, rebound hypertension)

Important Clinical Considerations

Risk Factors for Withdrawal Symptoms

• Longer duration of treatment (chronic vs. acute use) 5
• Higher doses
• Abrupt discontinuation rather than gradual tapering
• Concomitant medications that may interact with guanfacine

Differences from Clonidine

While both are alpha-2 agonists, guanfacine has:

• Less pronounced withdrawal syndrome compared to clonidine 5
• Longer duration of action (2-3 days offset of effects) 2
• More selective binding to alpha-2A receptors 6

Common Pitfalls to Avoid

1. Misdiagnosing withdrawal tremor as essential tremor

   • Withdrawal tremor is temporary and resolves with proper management
   • Essential tremor requires different long-term treatment approaches

2. Failing to recognize other withdrawal symptoms

   • Headache (common from day 2 onward) 2
   • Potential rebound hypertension
   • Increased salivary flow 2

3. Prolonged use of symptomatic treatments

   • Medications like propranolol should be used temporarily while guanfacine is properly tapered
   • Avoid creating new medication dependencies

Prevention of Withdrawal Symptoms

For future reference, always taper guanfacine gradually rather than stopping abruptly. The European Society of Cardiology specifically warns that "sudden cessation of treatment can produce a withdrawal syndrome" with central acting antihypertensive drugs including guanfacine 1.

Special Populations

• In children with ADHD, withdrawal symptoms may be mistaken for return of ADHD symptoms
• In elderly patients, monitor more closely for orthostatic hypotension during tapering
• In patients with cardiovascular disease, more gradual tapering may be necessary