What is the recommended tapering schedule for an adult on propranolol (Inderal LA) extended‑release?

How to Wean Off Propranolol Inderal LA Extended-Release

Critical Distinction: Cardiovascular vs. Non-Cardiovascular Indications

For cardiovascular indications (angina, post-MI, hypertension, arrhythmias), propranolol must be tapered gradually over at least 2–3 weeks to prevent potentially life-threatening rebound phenomena including angina exacerbation, myocardial infarction, ventricular arrhythmias, and sudden death. 1, 2, 3

In contrast, for infantile hemangiomas, propranolol can be stopped abruptly without tapering. 2 However, since you are asking about Inderal LA (extended-release) in an adult context, the cardiovascular tapering protocol applies.

Evidence for Mandatory Tapering

• A landmark 1975 study documented that abrupt propranolol withdrawal in patients on 160–320 mg daily caused serious complications in 6 of 20 patients within two weeks, including intermediate coronary syndrome (3 patients), ventricular tachycardia, fatal myocardial infarction, and sudden death. 3
• The rebound phenomenon results from enhanced beta-adrenergic sensitivity that develops during chronic propranolol therapy; abrupt cessation unmasks this hypersensitivity, precipitating rebound hypertension, tachycardia, and angina. 1, 4
• The FDA label explicitly states: "If treatment is to be discontinued, reduce dosage gradually over a period of a few weeks." 5

Recommended Tapering Schedule

Standard Taper Protocol

Reduce the daily dose by approximately 25–50% every 3–7 days over a minimum of 2–3 weeks, with closer monitoring in patients with coronary artery disease. 1, 5, 4

Example for a patient on 160 mg once daily:

• Week 1: Reduce to 120 mg once daily
• Week 2: Reduce to 80 mg once daily
• Week 3: Reduce to 40 mg once daily
• Week 4: Discontinue completely

Enhanced Safety Protocol (Prolonged Low-Dose Taper)

For patients at highest risk (history of angina, prior myocardial infarction, or significant symptom relief from propranolol), maintain a prolonged low dose of 30 mg daily for 2 weeks before complete discontinuation. 4

• Research demonstrates that this prolonged small-dose strategy prevents cardiac hypersensitivity, rebound tachycardia, blood pressure overshoot, and catecholamine surge more effectively than simple serial dose reduction. 4
• This approach is particularly important when the patient had severe pre-treatment angina that was well-controlled by propranolol. 3

Monitoring During Taper

Assess heart rate, blood pressure, and anginal symptoms at each dose reduction and 1–2 weeks after complete discontinuation. 1

• Watch for signs of rebound: resting heart rate >20 beats/min above baseline, systolic blood pressure increase >20 mm Hg, new or worsening chest pain, palpitations, or anxiety. 1, 3
• If rebound symptoms develop, resume the previous dose and taper more slowly. 1

Activity Restriction

Advise patients to restrict physical activity during the withdrawal period, as exercise may unmask rebound ischemia. 3

Common Pitfalls to Avoid

• Never stop propranolol abruptly in patients with cardiovascular indications, even if the patient is asymptomatic or the dose seems "low." 1, 5, 3
• Do not assume extended-release formulations are safer to stop suddenly—the same rebound risk applies regardless of formulation. 5, 6
• Avoid tapering too quickly (e.g., stopping after only 1 week)—the enhanced beta-adrenergic sensitivity persists for at least 2 weeks after cessation. 3, 4
• Do not taper during acute illness—if the patient has reduced oral intake or vomiting, temporarily hold the dose and resume at a lower level once stable, then continue the planned taper. 1

Special Circumstances: Temporary Holding vs. Permanent Discontinuation

If propranolol must be held temporarily due to acute illness (vomiting, reduced oral intake, wheezing requiring treatment), it may be stopped without taper and restarted at a lower dose once the patient recovers. 1, 2

This temporary interruption strategy applies only to short-term holds (days); permanent discontinuation for cardiovascular indications always requires gradual tapering. 1, 2

Pharmacokinetic Considerations

• Propranolol extended-release has a terminal half-life of 8–11 hours, meaning drug effects dissipate within 24–48 hours after the last dose. 6, 7
• Despite rapid drug clearance, the physiologic rebound (enhanced beta-receptor sensitivity) persists for 1–2 weeks, necessitating the prolonged taper. 3, 4, 7
• The extended-release formulation produces lower peak concentrations but maintains therapeutic levels over 24 hours, so once-daily dosing during taper is appropriate. 5, 6