Gradual Dose Reduction of Guanfacine 4 mg for ADHD
Taper guanfacine by reducing the dose by 1 mg every 3-7 days to avoid rebound hypertension. 1
Recommended Tapering Schedule
For a patient on guanfacine 4 mg daily, follow this specific reduction protocol:
- Week 1: Reduce to 3 mg daily for 3-7 days 1
- Week 2: Reduce to 2 mg daily for 3-7 days 1
- Week 3: Reduce to 1 mg daily for 3-7 days 1
- Week 4: Discontinue after completing the 1 mg phase 1
The total tapering period should span approximately 2-4 weeks depending on whether you use 3-day or 7-day intervals between dose reductions. 1
Critical Safety Warnings
Never abruptly discontinue guanfacine—this can precipitate rebound hypertension and potential hypertensive crisis. 1 This is the most important safety consideration when stopping this medication, as guanfacine is an alpha-2A adrenergic receptor agonist with antihypertensive effects. 1
Cardiovascular Monitoring During Taper
- Monitor blood pressure and heart rate at each dose reduction step 1
- Watch for signs of rebound hypertension including elevated BP readings, headache, anxiety, or tremor 1
- Patients should be instructed to report any chest pain, palpitations, or severe headaches immediately 1
Special Considerations
If Doses Are Accidentally Missed
If a patient accidentally misses multiple doses, do not restart at the full 4 mg dose without medical guidance. 1 The patient should contact their healthcare provider to determine the appropriate restart dose, which may require re-titration from a lower dose. 1
Evidence for Tapering Approach
While one small study in healthy young adults (ages 19-24) suggested that abrupt cessation of guanfacine ER up to 4 mg did not cause clinically significant BP elevations compared to taper-down, 2 current clinical guidelines universally recommend tapering to minimize risk in real-world patients with ADHD who may have different cardiovascular profiles. 1 The guideline recommendation of 1 mg reduction every 3-7 days represents the safest approach for clinical practice. 1
Timing of Dose Reductions
Continue administering guanfacine at the same time of day during the taper (typically evening dosing). 1 Maintain the once-daily schedule throughout the discontinuation process. 3
Common Pitfalls to Avoid
- Do not taper too quickly: Rushing the taper increases rebound hypertension risk 1
- Do not skip cardiovascular monitoring: BP and HR should be checked at each dose reduction 1
- Do not assume immediate-release and extended-release formulations can be tapered identically: This guidance applies specifically to guanfacine extended-release formulations 1, 2