How to discontinue blood pressure medications?

How to Discontinue Blood Pressure Medications

For patients with well-controlled hypertension on a single medication, discontinuation can be attempted if home BP monitoring consistently shows diastolic BP <80 mm Hg, but expect only 28-51% to remain normotensive at 6 months, requiring close monitoring and readiness to restart therapy. 1, 2

When Discontinuation is Appropriate

Confirm eligibility before stopping any antihypertensive:

• Home BP readings consistently <130/80 mm Hg for at least 6 months on a single medication 1
• No target organ damage (no history of stroke, MI, heart failure, or chronic kidney disease) 1
• Absence of severe baseline hypertension (never had SBP ≥180 mm Hg or DBP ≥110 mm Hg) 1
• No pre-existing cardiovascular disease 1

Critical caveat: Office BP alone is insufficient—you must confirm with home monitoring to exclude white coat hypertension before considering discontinuation. 1

Drug-Specific Discontinuation Hierarchy

Never stop these medications abruptly:

• Beta-blockers: Taper over 7-10 days minimum to prevent rebound tachycardia, severe hypertension, and potential MI or angina, especially in patients with coronary artery disease 3, 1, 4
• Clonidine and central alpha-agonists: Taper over 7-10 days to avoid dangerous rebound hypertension with headache, agitation, and tremor within 24-72 hours 1, 4

Can be stopped more safely (but still taper):

• ACE inhibitors/ARBs: Gradual discontinuation over 7-10 days, though acute withdrawal symptoms are fewer 1, 4
• Calcium channel blockers: Taper to avoid reflex tachycardia and BP elevation 1
• Diuretics: Can be stopped but monitor for fluid retention 4

Structured Discontinuation Protocol

Follow this stepwise approach:

1. Stop one medication at a time if patient is on multiple agents—never discontinue all simultaneously 1

2. Taper the selected medication over 7-10 days rather than abrupt cessation 4

3. Initiate home BP monitoring before discontinuation and continue daily for first 2 weeks, then weekly 1

4. Schedule follow-up at 2-4 weeks after complete discontinuation to reassess BP 1

5. Restart medication immediately if home BP reaches SBP ≥140 mm Hg or DBP ≥90 mm Hg 1

Special Clinical Scenarios Requiring Different Approaches

Heart failure with reduced ejection fraction (HFrEF):

• Do NOT completely discontinue guideline-directed medical therapy (GDMT) even with low BP 3
• When SBP <80 mm Hg with symptoms, follow this hierarchy: First reduce/stop non-GDMT medications, then if needed, reduce (not stop) RAS inhibitors if eGFR <30 ml/min/1.73 m² 3
• Most hypotension in HFrEF trials was NOT attributable to medications—consider whether symptoms truly warrant discontinuation 3

Acute illness with volume depletion:

• Temporarily stop ACE inhibitors/ARBs, diuretics, and ARNIs during vomiting, diarrhea, or reduced oral intake 5
• Restart at usual doses within 24-48 hours of resuming normal eating and drinking 5
• Stop SGLT2 inhibitors in diabetics to prevent ketoacidosis 5

Perioperative management:

• Continue beta-blockers and avoid stopping on day of surgery 3
• Consider holding ACE inhibitors/ARBs 24 hours before surgery to reduce intraoperative hypotension risk 3
• Never abruptly stop clonidine or beta-blockers perioperatively 3

Monitoring After Discontinuation

Implement structured surveillance:

• Home BP monitoring daily for first 2 weeks, then weekly for 3 months 1
• Office visit at 2-4 weeks post-discontinuation 1
• Annual monitoring indefinitely even if BP remains controlled—this is lifelong surveillance 1
• Watch for symptoms: headache, chest pain, visual changes, or dyspnea 1

Expected Outcomes and Patient Counseling

Set realistic expectations:

• Only 51% remain normotensive at 6 months and 28% at 195 days after stopping a single medication 2
• Younger patients and those on single low-dose therapy have better success rates 6
• Psychological distress and anxiety about stopping medications is common and may require emotional support 2

Educate patients about warning signs:

• Report lightheadedness, especially in first few days 7
• Seek immediate care for chest pain, severe headache, or neurological symptoms 1
• Understand that excessive perspiration, vomiting, or diarrhea can cause dangerous BP drops 7

Common Pitfalls to Avoid

• Do not rely solely on office BP readings—white coat hypertension affects up to 20% of patients 1
• Do not stop all medications simultaneously in patients on combination therapy 1
• Do not discontinue beta-blockers or clonidine abruptly under any circumstances 3, 1, 4
• Do not assume well-controlled BP means medications can be stopped—most patients will require resumption of therapy 2
• Do not discontinue GDMT in HFrEF patients based on low BP alone without addressing other causes first 3

When Discontinuation Fails

If BP becomes elevated after stopping:

• Restart the same medication at the previous effective dose 1
• Consider that dose reduction rather than complete discontinuation may be more successful—approximately 50% more patients maintain BP control with dose reduction versus complete cessation 6
• Reducing to half the previous dose is significantly more effective than stopping entirely 6