Can propranolol (a beta blocker) be safely discontinued abruptly or does it require a taper?

From the Guidelines

Propranolol should not be discontinued abruptly but rather tapered down gradually under medical supervision. This recommendation is based on the guidelines provided by the American College of Cardiology/American Heart Association task force on clinical practice guidelines, which explicitly state "Avoid abrupt cessation" for propranolol, among other beta blockers 1. Sudden discontinuation of propranolol can lead to withdrawal symptoms including increased heart rate, elevated blood pressure, worsening angina, and in some cases, heart attacks or severe cardiac events.

Key Considerations for Tapering Propranolol

• A typical tapering schedule might involve reducing the dose by 25-50% every 1-2 weeks, but this should be personalized by your healthcare provider based on your specific condition, current dosage, and how long you've been taking the medication.
• For example, someone on 80mg twice daily might reduce to 40mg twice daily for a week, then 20mg twice daily, and so on.
• The tapering process is particularly important for patients taking propranolol for cardiovascular conditions like hypertension, angina, or arrhythmias, as it allows the body to adjust to decreasing levels of beta-blockade and prevents a sudden increase in sympathetic nervous system activity, which can strain the heart.
• Even patients taking low doses for conditions like anxiety or essential tremor should follow a tapering schedule to minimize potential withdrawal effects, as indicated by the general principle of avoiding abrupt cessation of beta blockers like propranolol 1.

Importance of Medical Supervision

• The decision to taper off propranolol and the tapering schedule should be made under the guidance of a healthcare provider.
• Monitoring during the tapering process is crucial to manage any potential withdrawal symptoms and to adjust the tapering schedule as needed.
• The healthcare provider will consider the patient's overall health, the reason for taking propranolol, and any other medications the patient is taking when determining the best approach for tapering off propranolol.

From the FDA Drug Label

WARNINGS Angina Pectoris: There have been reports of exacerbation of angina and, in some cases, myocardial infarction, following abrupt discontinuance of propranolol therapy Therefore, when discontinuance of propranolol is planned, the dosage should be gradually reduced over at least a few weeks, and the patient should be cautioned against interruption or cessation of therapy without the physician’s advice If treatment is to be discontinued, reduce dosage gradually over a period of a few weeks (see "WARNINGS")

Propranolol discontinuation should be done gradually, over at least a few weeks, to avoid potential exacerbation of angina and myocardial infarction 2.

• The dosage should be reduced gradually to minimize risks.
• Abrupt discontinuation is not recommended due to the risk of adverse cardiac events 2.
• It may be advisable to withdraw the drug gradually over a period of several weeks, depending on the patient’s age, comorbidity, and dose of propranolol 2.

From the Research

Propranolol Discontinuation

• Propranolol should not be discontinued abruptly, as it may lead to a "propranolol withdrawal syndrome" due to enhanced beta adrenergic sensitivity 3, 4.
• Tapering propranolol dosage is frequently used to prevent adverse withdrawal events, but the success of such a maneuver has not been consistently shown 3.
• A study found that serial dose reduction of propranolol decreased but did not prevent cardiac hypersensitivity in two of three patients 3.
• However, prolonged administration of small dose propranolol before complete withdrawal largely prevented cardiac hypersensitivity and other adverse events 3.
• Another study found that abrupt discontinuation of propranolol led to transient supersensitivity to the chronotropic effects of isoproterenol, beginning 2-6 days after propranolol withdrawal 4.

Comparison with Other Antihypertensive Agents

• Rebound hypertension has been reported during clonidine withdrawal, but not during beta-adrenergic blockade therapy cessation 5.
• Clonidine withdrawal has been associated with a high incidence of rebound hypertension and tachycardia, with symptoms of sympathetic overactivity and increased catecholamine excretion 6, 7.
• A regimen comprising high doses of prazosin, atenolol, and chlordiazepoxide has been successful in preventing the hemodynamic and symptomatic features of clonidine withdrawal 6.