Beta Blocker Withdrawal: A Clinical Approach
As a clinical pharmacist, you’ll likely encounter concerns about beta blocker withdrawal, especially in patients with coronary artery disease (CAD). Stopping beta blockers abruptly can trigger rebound tachycardia, hypertension, angina, or even myocardial infarction. Serious ventricular arrhythmias and sudden cardiac death can also occur—even in patients without prior CAD symptoms.
These withdrawal effects stem from increased sympathetic activity due to beta receptor upregulation during chronic beta blockade. The risk depends on how quickly beta blockade wears off compared to receptor downregulation (which takes 24 to 36 hours). Expect withdrawal to be more pronounced with short-acting beta blockers (e.g., propranolol) since the adrenergic rebound outlasts the drug's effects. Gradual tapering lowers this risk.
- When stopping a beta blocker, taper based on half-life:
- Short-acting beta blockers (e.g., propranolol, carvedilol): Take usual dose once daily for 1 week, then every other day for 1 week, then stop.
- Long-acting beta blockers (e.g., atenolol, nadolol): Take half the usual dose once daily for 1 week, then half the dose every other day for 1 week, then stop.
A faster taper can be used if necessary—half-dose every other day for 1 week usually suffices. Don't assume beta blocker withdrawal is harmless. Watch for rebound tachycardia, hypertension, or angina—especially in high-risk patients. If a patient has to stop a beta blocker suddenly, consider alternative agents such as non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) to blunt the rebound effect.
References
- Miller RR, Olson HG, Amsterdam EA, Mason DT. Propranolol-withdrawal rebound phenomenon. Exacerbation of coronary events after abrupt cessation of antianginal therapy. N Engl J Med. 1975;293(9):416-418.
- Psaty BM, Koepsell TD, Wagner EH, LoGerfo JP, Inui TS. The relative risk of incident coronary heart disease associated with recently stopping the use of beta-blockers. JAMA. 1990;263(12):1653-1657.
- Krukemyer JJ, Boudoulas H, Binkley PF, Lima JJ. Comparison of hypersensitivity to adrenergic stimulation after abrupt withdrawal of propranolol and nadolol: influence of half-life differences. Am Heart J. 1990;120(3):572-579.
