When can hypertensive (high blood pressure) maintenance medications, such as ACE (Angiotensin-Converting Enzyme) inhibitors and calcium channel blockers, be stopped?

When to Stop Hypertensive Maintenance Medications

Antihypertensive medications should generally be continued indefinitely, but withdrawal can be considered in select patients with well-controlled mild hypertension who meet specific criteria, with the understanding that approximately 60-74% will require medication reinitiation within 1-2 years. 1

Candidates for Medication Withdrawal

Patients most likely to remain normotensive after stopping antihypertensive therapy include those with the following characteristics 2, 1:

• Mild essential hypertension (previously well-controlled on monotherapy)
• Young age
• Normal body weight
• Low pretreatment blood pressure (before starting medications)
• Minimal or no target organ damage (no left ventricular hypertrophy, chronic kidney disease, or retinopathy)
• Low salt intake and no alcohol consumption
• Successfully controlled on a single drug only

Critical Contraindications to Abrupt Withdrawal

Never abruptly discontinue beta-blockers or clonidine, as this is potentially harmful and can cause rebound hypertension, enhanced sympathetic activity, and cardiovascular events. 3, 4

High-Risk Situations for Withdrawal Syndrome 4:

• Patients on high doses of centrally acting antiadrenergic drugs (clonidine)
• Patients on beta-blockers, especially with ischemic heart disease
• Severe hypertension or renovascular hypertension
• Multiple antihypertensive drugs at high doses

Safe Withdrawal Protocol

If withdrawal is attempted, the following approach is mandatory 4, 1:

• Gradual tapering over 7-10 days minimum (not abrupt cessation)
• Frequent blood pressure monitoring during and after withdrawal (at minimum monthly for first 6 months)
• Patient education about symptoms of rebound hypertension (headache, palpitations, general malaise)
• Immediate reinitiation of medication if blood pressure rises above treatment threshold

Expected Outcomes After Withdrawal

The evidence shows 1:

• 38% remain normotensive at 6 months
• 40% remain normotensive at 1 year
• 26% remain normotensive at 2 years or longer

This means the majority (60-74%) will require medication reinitiation.

Special Circumstances Where Continuation is Mandatory

Perioperative Period

Continue antihypertensive medications through surgery, with the possible exception of ACE inhibitors/ARBs which may be considered for discontinuation perioperatively. 3

• Beta-blockers must be continued if chronically used 3
• Abrupt preoperative discontinuation of beta-blockers or clonidine is potentially harmful 3

Heart Failure

Never discontinue ACE inhibitors in patients with heart failure, as abrupt withdrawal can lead to clinical deterioration. 3

After Bevacizumab Therapy

Hypertension induced by bevacizumab typically resolves after treatment completion, and antihypertensive medications should be reassessed and potentially discontinued 4 weeks after stopping bevacizumab. 3

Medications Safe vs. Unsafe for Intermittent Compliance

If a patient has poor adherence, drug selection matters 5:

Safe with missed doses:

• Diuretics
• ACE inhibitors
• ARBs (long-acting formulations)

Dangerous with missed doses:

• Short-acting beta-blockers
• Clonidine
• Short-acting dihydropyridines (cause rebound sympathetic activation)

Common Pitfalls to Avoid

• Do not stop medications simply because blood pressure is below target - if well-tolerated, continue therapy 3
• Do not assume all patients with "controlled" hypertension can stop medications - only 26-40% maintain normotension long-term 1
• Do not attempt withdrawal without establishing a monitoring plan - most patients will need reinitiation 1
• Do not withdraw medications in patients with diabetes, chronic kidney disease, or cardiovascular disease - these patients require indefinite therapy 3, 6