In a terminal cancer patient with a life expectancy of months to weeks who has been on chronic antihypertensive therapy for years, is it safe to discontinue these medications or could stopping them precipitate a rapid, fatal hypertensive crisis?

Discontinuing Antihypertensives in Terminal Cancer Patients

In terminal cancer patients with months-to-weeks life expectancy who have been on chronic antihypertensive therapy, you should discontinue these medications because the risk of fatal hypertensive crisis is extremely low and far outweighed by the burden of unnecessary polypharmacy—antihypertensives require months to years to provide mortality benefit, which these patients will never realize. 1

Why Discontinuation is Safe and Appropriate

Time-to-Benefit Mismatch

• Antihypertensive medications require months to years to produce mortality or morbidity benefit, far exceeding the weeks-to-months remaining lifespan of palliative patients 1
• The STOPPFrail 2021 criteria explicitly specify that patients with end-stage irreversible disease and poor 1-year survival prognosis should have cardiovascular preventive drugs deprescribed unless needed for active symptom control 1
• For patients with months-to-weeks life expectancy, guidelines recommend actively discontinuing drugs with long time-to-benefit and prioritizing symptom-directed therapy 1

Actual Risk of Hypertensive Crisis is Minimal

• The concern about "rapid, fatal hypertensive crisis" is largely theoretical in this population—the short-term absolute risk of moderately elevated blood pressure is low 2
• Even in active cancer treatment contexts, blood pressure <160/100 mmHg does not require urgent intervention, and the threshold for concern is much higher than baseline hypertension 2
• Malignant-phase hypertension, hypertensive crisis, or hypertensive encephalopathy are the only true emergencies requiring intervention, and these are exceedingly rare in patients simply discontinuing chronic antihypertensives 2

Polypharmacy Harms Outweigh Benefits

• Polypharmacy in palliative patients is associated with drug-drug interactions, toxicity, falls, delirium, and non-adherence, all of which increase adverse-event risk 1
• Continuing medications "just in case" due to clinician fear of liability adds unnecessary pill burden without benefit 1
• The NCCN recommends that patients with months-to-weeks life expectancy should consider discontinuation of disease-modifying treatments and focus on quality of life 2, 1, 3

How to Safely Discontinue

Medications That Can Be Stopped Abruptly

• Most antihypertensives including ACE inhibitors, ARBs, calcium channel blockers (except non-dihydropyridines), and thiazide diuretics can be stopped abruptly without significant withdrawal risk 1
• Statins, aspirin, and bisphosphonates can also be stopped immediately 1

Medications Requiring Gradual Taper

• Beta-blockers must be tapered gradually over 2-4 days to avoid rebound hypertension and tachycardia 1
• Clonidine requires special caution—the FDA label explicitly warns that sudden cessation can result in nervousness, agitation, headache, tremor, and rapid rise in blood pressure with elevated catecholamines 4
• Clonidine should be reduced gradually over 2-4 days to avoid withdrawal symptomatology, and rare instances of hypertensive encephalopathy, cerebrovascular accidents, and death have been reported after abrupt withdrawal 4
• If clonidine withdrawal hypertension occurs, it can be reversed by re-administering oral clonidine or intravenous phentolamine 4

Practical Deprescribing Algorithm

• Discontinue one medication at a time to allow monitoring for withdrawal symptoms or clinical changes 1
• Start with medications that have no withdrawal risk (ACE inhibitors, ARBs, calcium channel blockers) 1
• Taper beta-blockers and clonidine over 2-4 days if present 1, 4
• Monitor blood pressure casually (not aggressively) during the first week after discontinuation—only intervene if symptomatic hypertension develops (headache, visual changes, altered mental status) 2

Communication and Documentation

Reframe the Conversation

• Never describe discontinuation as "giving up"—instead, reframe it as "fighting for better quality of life" by reducing pill burden and side effects 2, 1, 3
• Confirm patient understanding of their prognosis and goals of care, as many patients lack clear understanding despite prior discussions 1, 3

Document the Decision

• Document deprescribing decisions after shared discussion with the patient and family to ensure clarity, continuity of care, and protection against misunderstandings 1
• Explicitly note that the decision was made to prioritize quality of life over theoretical long-term cardiovascular risk reduction 1

Common Pitfalls to Avoid

• Do not continue antihypertensives indefinitely in terminal patients simply because they've been on them for years—this is inappropriate polypharmacy 1, 5
• Do not abruptly stop clonidine or beta-blockers without tapering—these require gradual dose reduction 1, 4
• Do not aggressively treat asymptomatic blood pressure elevations in dying patients—the focus should be on symptom control, not numbers 2
• Do not assume the patient understands their prognosis just because you've discussed it—explicitly confirm understanding before deprescribing 1, 3