Switching from Propranolol to Amlodipine: No Taper Required
You can switch directly from propranolol 40 mg BID to amlodipine without any taper, starting amlodipine 5 mg once daily on the same day you stop propranolol. 1, 2
Rationale for Direct Switch
Propranolol at 40 mg BID is a low dose (usual angina dosing is 20-80 mg BID per ACC/AHA guidelines), which significantly reduces withdrawal risk 3
The patient has uncomplicated hypertension, not post-MI or unstable angina where abrupt beta-blocker cessation poses greater risk 3
Research demonstrates that prolonged small-dose propranolol (30 mg daily for 2 weeks) prevents withdrawal syndrome, but your patient is already at a low dose (80 mg total daily), making taper unnecessary 2
Amlodipine has a 40-60 hour half-life and takes 6-8 hours to reach peak effect, providing gradual blood pressure control that prevents any rebound hypertension during the transition 1
Specific Switching Protocol
Stop propranolol 40 mg BID completely
Monitor blood pressure weekly for 3-4 weeks until steady-state is achieved (amlodipine reaches steady-state in 7-10 days) 1, 4
Titrate amlodipine to 10 mg once daily if blood pressure remains >140/90 mmHg after 2 weeks 3, 4, 5
When Taper IS Required (Not Your Case)
High-dose propranolol (>160 mg daily) in post-MI patients requires taper: reduce to 30 mg daily for 2 weeks before complete discontinuation 2
Patients with unstable angina, recent MI (within 3 months), or heart failure: maintain beta-blocker and add amlodipine rather than switching 3
Hemodynamically unstable patients or those with severe LV dysfunction: avoid abrupt beta-blocker cessation 3
Critical Monitoring Points
Check blood pressure at 1 week, 2 weeks, and 4 weeks post-switch to ensure adequate control and assess need for dose adjustment 1, 4
Watch for amlodipine-induced peripheral edema (occurs in first 3 months): if develops, add ACE inhibitor or ARB rather than stopping amlodipine 6
Assess for symptoms of beta-blocker withdrawal (tachycardia, tremor, anxiety, rebound hypertension): extremely unlikely at this low dose but monitor heart rate at first visit 2
Avoid NSAIDs and other vasodilators that may compound amlodipine's effects 6
Expected Blood Pressure Response
Amlodipine 5-10 mg once daily reduces blood pressure by approximately 12-16/10-12 mmHg in mild-to-moderate hypertension 7, 5
Blood pressure decreases gradually over 4-8 hours after first dose, with minimal heart rate change due to lack of reflex tachycardia 1
If blood pressure remains uncontrolled after 2 weeks on amlodipine 10 mg daily, add a second agent (ACE inhibitor, ARB, or thiazide diuretic) rather than further increasing amlodipine 6