What is the recommended tapering schedule for a child or adolescent with Attention Deficit Hyperactivity Disorder (ADHD) when discontinuing guanfacine (Intuniv)

Tapering Guanfacine in Children and Adolescents with ADHD

Guanfacine must be tapered gradually rather than abruptly discontinued to prevent rebound hypertension, with a recommended taper schedule of reducing the dose by 1 mg every 3-7 days. 1, 2, 3

Why Tapering is Critical

• Rebound hypertension is the primary safety concern when discontinuing guanfacine or clonidine abruptly, though this complication occurs less frequently with guanfacine compared to clonidine due to guanfacine's longer half-life 1
• The FDA label notes that when rebound hypertension does occur, it typically manifests 2-4 days after abrupt cessation, which is delayed compared to clonidine 4
• In most cases after abrupt withdrawal, blood pressure returns to pretreatment levels slowly (within 2-4 days) without ill effects, but the risk of rebound necessitates a cautious approach 4

Recommended Taper Schedule

The standard taper protocol is to decrease by 1 mg every 3-7 days until discontinuation is complete. 2, 3

Practical Implementation:

• For a child on 4 mg daily: reduce to 3 mg for 3-7 days, then 2 mg for 3-7 days, then 1 mg for 3-7 days, then discontinue 2, 3
• For a child on 2 mg daily: reduce to 1 mg for 3-7 days, then discontinue 2, 3
• The slower end of this range (every 7 days) is preferable for patients on higher doses or those with cardiovascular concerns 2, 3

Monitoring During Taper

Blood pressure and heart rate must be monitored at each dose reduction and for several days after complete discontinuation. 2, 3

• Check vital signs before each dose reduction 2, 3
• Monitor for symptoms of rebound hypertension including headache, which was reported in 4 of 5 patients in withdrawal studies 5
• Continue monitoring for at least 4-7 days after the final dose, as rebound effects may be delayed 4, 5

ADHD Symptom Monitoring

Develop a specific monitoring plan for return of ADHD symptoms, as the timeline differs from cardiovascular effects. 1

• Hyperactivity symptoms may return within hours to days after discontinuation 1
• Inattentive symptoms may take longer to re-emerge and require extended monitoring over weeks 1
• Obtain teacher and parent rating scales before tapering and at regular intervals during and after discontinuation 2

Evidence Supporting Gradual Taper

The recommendation for gradual tapering is based on:

• Guideline consensus: The American Academy of Pediatrics explicitly states that guanfacine should be tapered rather than suddenly discontinued due to observed rebound hypertension 1
• Research evidence: A Phase I study in healthy young adults (ages 19-24) found that abrupt cessation of guanfacine ER up to 4 mg daily did not produce significant rebound hypertension compared to taper-down, but this was in a healthy population without ADHD 6
• Clinical experience: Studies in hypertensive adults showed gradual blood pressure recovery over 2-4 days after withdrawal, with some patients experiencing transitory heart rate increases of 10-30 beats/min 5, 7

Important Caveats

• The research showing safety of abrupt discontinuation was conducted in healthy young adults, not children with ADHD, making the guideline recommendation for gradual taper more clinically appropriate for pediatric ADHD patients 6
• If multiple doses are accidentally missed, do not restart at the full dose without medical guidance—contact the prescriber to determine appropriate restart dosing 3
• Patients with pre-existing cardiovascular conditions require more cautious tapering and closer monitoring 2, 3
• The taper schedule may need to be slower (extending beyond 7 days per dose reduction) if withdrawal symptoms emerge during the taper 1

Special Considerations for Combination Therapy

• If guanfacine is being used adjunctively with a stimulant, the guanfacine should typically be tapered first while maintaining the stimulant, as guanfacine was added as an augmenting agent 1
• Continue monitoring both blood pressure and heart rate during taper, as stimulants have opposing cardiovascular effects (increasing BP and HR) that may partially offset guanfacine withdrawal effects 2