From the Guidelines
Guanfacine should be tapered when discontinuing rather than stopped abruptly to avoid rebound hypertension and other withdrawal effects. A typical taper involves reducing the dose by 1 mg every 3-7 days until completely discontinued, as suggested by the clinical practice guideline 1. For example, if a patient is taking 3 mg daily, they would decrease to 2 mg daily for 3-7 days, then to 1 mg daily for 3-7 days before stopping completely. Abrupt discontinuation of guanfacine can lead to rebound hypertension, increased heart rate, nervousness, agitation, headache, and tremor. These withdrawal effects occur because guanfacine is an alpha-2 adrenergic agonist that reduces sympathetic outflow from the brain. When stopped suddenly, there can be a surge in catecholamines (adrenaline and noradrenaline) as the body has adapted to the medication's presence. Patients with cardiovascular conditions may be at particular risk for complications from abrupt discontinuation. The taper schedule may need to be more gradual for patients who have been on higher doses or taking the medication for longer periods.
Some key points to consider when tapering guanfacine include:
- Gradually reducing the dose to minimize withdrawal effects
- Monitoring the patient's blood pressure and heart rate during the taper
- Being aware of the potential for rebound hypertension and other withdrawal effects
- Adjusting the taper schedule as needed based on the patient's response
It's also important to note that the evidence for tapering guanfacine is based on the medication's pharmacology and the potential risks of abrupt discontinuation, rather than on specific clinical trials or studies 1. However, the general principles of tapering medications to avoid withdrawal effects are well-established in the medical literature 1.
From the FDA Drug Label
Rebound Abrupt cessation of therapy with orally active central α 2-adrenergic agonists may be associated with increases (from depressed on-therapy levels) in plasma and urinary catecholamines, symptoms of "nervousness and anxiety" and, less commonly, increases in blood pressure to levels significantly greater than those prior to therapy Further, if guanfacine is to be discontinued in such patients, careful tapering of the dosage may be necessary in order to avoid rebound phenomena (see Reboundabove)
Yes, you need to taper guanfacine to avoid rebound phenomena, such as:
- Increases in plasma and urinary catecholamines
- Symptoms of "nervousness and anxiety"
- Increases in blood pressure to levels significantly greater than those prior to therapy 2 2
From the Research
Guanfacine Tapering
- The need to taper guanfacine is supported by studies that show a withdrawal syndrome may occur when the drug is abruptly discontinued 3, 4, 5.
- Guanfacine withdrawal has been associated with a gradual increase in blood pressure over 2-4 days, which is generally milder than the withdrawal syndrome seen with clonidine 6, 4, 5.
- Symptoms of guanfacine withdrawal are typically mild and may include headache, but do not usually involve significant catecholamine excess or rebound hypertension 4, 5.
- The pharmacokinetic properties of guanfacine, including its relatively long elimination half-life, suggest that tapering may not be necessary in all cases, but it is still recommended to minimize the risk of withdrawal symptoms 3, 6.
- Studies in animal models have shown that guanfacine can produce daily fluctuations in blood pressure, but the relevance of these findings to human patients is unclear 7.