What is a recommended taper schedule for an adult patient with Attention Deficit Hyperactivity Disorder (ADHD) or hypertension taking Tenex (Guanfacine) 2 mg daily?

Tenex (Guanfacine) 2 mg Taper Schedule

Recommended Tapering Protocol

For an adult on Tenex (guanfacine) 2 mg daily, taper gradually over 2-4 weeks by reducing the dose by approximately 33-50% every 1-2 weeks, monitoring blood pressure and heart rate at each reduction and for 7 days after complete discontinuation. 1, 2

Week-by-Week Schedule

Week 1-2: Reduce from 2 mg to 1 mg daily (50% reduction)

• Monitor blood pressure and heart rate at baseline and during this period 1
• Watch for rebound hypertension, tachycardia, or hypertonia 1

Week 3-4: Reduce from 1 mg to 0.5 mg daily (50% reduction of current dose)

• Continue monitoring cardiovascular parameters 1
• If using for ADHD, distinguish return of ADHD symptoms from true withdrawal phenomena 1

Week 5: Discontinue completely

• Monitor blood pressure and heart rate for 7 days after final dose 1
• The FDA label notes that rebound hypertension can occur 2-4 days after cessation, though the frequency is low 2

Alternative Slower Taper (If Needed)

If you have been on guanfacine for more than 1 year or experience withdrawal symptoms during the standard taper, use a slower schedule: 1

• Reduce by 0.5 mg every 2-4 weeks
• This would mean: 2 mg → 1.5 mg (weeks 1-4) → 1 mg (weeks 5-8) → 0.5 mg (weeks 9-12) → discontinue

Critical Safety Considerations

Never stop guanfacine abruptly. Gradual tapering is essential to minimize risks of rebound hypertension, tachycardia, and hypertonia, particularly if used for more than 9 weeks. 1 The FDA label confirms that while most patients return to pretreatment blood pressure levels slowly within 2-4 days without ill effects after abrupt withdrawal, rebound hypertension can occur and is delayed compared to clonidine due to guanfacine's longer half-life. 2

Monitoring Requirements

Check the following at each dose reduction and for 7 days after complete discontinuation: 1

• Blood pressure: Watch for elevations above baseline, particularly systolic increases
• Heart rate: Monitor for rebound tachycardia (increases in heart rate) 1
• Withdrawal symptoms: Assess for headache, nervousness, or anxiety

In adults with ADHD, blood pressure and heart rate should be checked at baseline and periodically during treatment, as minor but statistically significant changes can occur. 3

Management of Withdrawal Symptoms

If withdrawal symptoms occur during tapering: 1

• Slow the taper immediately by extending time at the current dose by 1-2 weeks before attempting further reduction
• For severe rebound hypertension: Consider temporary use of an alternative antihypertensive while resuming guanfacine at the previous tolerated dose 1

Common withdrawal symptoms to monitor include increased blood pressure, increased heart rate, headache, and anxiety. 1

Special Population Considerations

Patients with cardiovascular disease: Require more cautious monitoring during taper due to baseline cardiac risk. 1

Patients on concurrent CYP3A4 inhibitors or inducers: May require dose adjustments during taper due to altered guanfacine metabolism. 1

Pediatric ADHD patients: Use the same gradual taper schedule, as abrupt discontinuation risks (including documented rebound hypertension) are similar to adults. 1

Common Pitfalls to Avoid

• Do not taper too quickly: The standard 2-4 week taper is appropriate for most patients, but those on long-term therapy need slower tapers 1
• Do not skip monitoring: Blood pressure and heart rate checks are essential at each step and for a week after discontinuation 1
• Do not confuse ADHD symptom return with withdrawal: In ADHD patients, distinguish between return of underlying symptoms versus true withdrawal phenomena 1
• Do not assume all patients tolerate the same taper rate: The taper must be adjusted based on individual tolerance and emergence of withdrawal symptoms 1