Do You Need To Taper Propranolol?
Propranolol is generally recommended to be slowly tapered before discontinuing to avoid rebound and withdrawal symptoms.
I have taken propranolol ER 60 mg since April 2018, one capsule daily. Now I am trying to stop all together. What would you recommend to gradually stop?
Abrupt discontinuation of any chronically administered beta blocker (i.e. beta-adrenergic blocking drug) can result in a variety of adverse reactions, some of which can be serious. These reactions include:
- Exacerbation of angina
- Migraine rebound
- Myocardial ischemia
- Myocardial infarction
- Ventricular arrhythmias
- Hypertensive rebound
In patients without any sort of cardiac or coronary artery disease, adverse reactions of propranolol withdrawal tend to be mild and short-lived (mild symptoms of anxiety or increased heart rate may be seen) (6).
The prescribing information for propranolol discusses discontinuation of the drug in a few different sections. Here is a section regarding possible adverse events if the drug is abruptly stopped:
"Severe exacerbation of angina and the occurrence of myocardial infarction have been reported in some patients with angina pectoris following abrupt discontinuation of propranolol hydrochloride therapy. Therefore, when discontinuation of INDERAL-LA [propranolol ER] is planned in patients with angina pectoris or ischaemic heart disease, the dosage should be gradually reduced over a period of at least two weeks and the patient should be carefully monitored."
The prescribing information goes on to give the following recommendation in regard to how to taper the dose:
"Discontinuation of INDERAL-LA can be achieved by substituting INDERAL-LA [propranolol ER] 60, 80, 120 and 160 mg by the equivalent dose of conventional propranolol hydrochloride tablets spread throughout the day, and then gradually reducing the dose. In situations of greater urgency, propranolol hydrochloride tablets or INDERAL-LA dosage should be reduced stepwise in four days, under close observation. If angina markedly worsens, or acute coronary insufficiency develops, it is recommended that treatment with conventional propranolol hydrochloride tablets be reinstituted promptly, at least temporarily. In addition, patients with angina pectoris or ischaemic heart disease should be warned against abrupt discontinuation of propranolol hydrochloride."
To summarize the above recommendations from the prescribing information:
- If chronic propranolol therapy is to be discontinued, the dosage should be gradually decreased over a minimum of 2 weeks.
- If prompt discontinuation of propranolol is required, it may be done more quickly, but only under observation.
- If exacerbation of angina occurs during discontinuation of therapy, it is advised to resume propranolol therapy and take alternative measures.
There are some additional issues with abrupt discontinuation of propranolol, including:
- If using for migraine prophylaxis, stopping the drug 'cold turkey' could exacerbate symptoms and increase frequency of migraines (4).
- Beta blockers, like propranolol, mask symptoms of hyperthyroidism, and therefore may not be properly diagnosed in some individuals. Abrupt withdrawal of beta-blockers in a patient with hyperthyroidism can precipitate thyroid storm (5).
How To Discontinue
Although the prescribing information for propranolol gives recommendations for discontinuing the drug, there is no single agreed upon way that will work for everyone.
It is important to discuss your particular medical situation with your doctor to decide on a proper plan in regard to stopping propranolol.
Nevertheless, various studies have recommended the following:
- If not using for cardiac related illnesses, taper over at least one week to avoid withdrawal symptoms.
- If using for coronary artery disease, taper over one to two weeks.
- For individuals with a history of myocardial infarction (i.e. heart attack), it may be prudent to taper over as long as three weeks, and having sublingual nitroglycerin available (7) for as needed symptoms.
If you are taking the extended release version of propranolol (propranolol ER), you may want to discuss switching to the immediate release product (as recommended in the prescribing information for the drug) to aid in tapering.
Propranolol is a non-selective beta-adrenergic receptor antagonist, also known as a beta-blocker.
Beta-blockers aren't recommended as a first-line treatment for hypertension (i.e. high blood pressure) but are recommend for high blood pressure patients with angina, prior myocardial infarction, or heart failure.
Propranolol was first approved by the FDA in 1967; an extended-release formulation designed for bedtime-dosing was approved in March 2003.
Regular-release propranolol should be taken before meals. Extended-release formulations should not be crushed or chewed and are generally recommended to be taken at bedtime.