Stopping beta blocker therapy

• consequences if abrupt withdrawal of a beta blocker
  • worsening angina, myocardial infarction and ventricular dysrhythmias have been observed after abrupt discontinuation of propranolol in patients with coronary artery disease (1)
  • abrupt withdrawal of beta-blocking drugs in patients with hypertension has resulted in transient symptoms, including malaise, headache, sweating, palpitations and increases in blood pressure
  • abrupt withdrawal of beta-blocker perioperatively is associated with increased postoperative mortality (2)
  • if abrupt withdrawal of beta blockers then coronary events have been observed to as late as 3 weeks after abrupt withdrawal of beta blocker therapy (1)
    
    
• gradual withdrawal of beta blocker usage
  • if chronic usage of a beta blocker then beta blocker therapy needs to be gradually withdrawn to minimise the consequences described above
  • the exact definition of how a beta blocker is to be gradually withdrawn is not described in the respective summary of product characteristics
    • however it has been stated (1) that, if chronic beta blocker usage, 14 days of gradual dose reduction before beta blocker withdrawal is necessary to prevent beta-adrenergic supersensitivity (and possibly "rebound" symptoms)
      • if chronic beta blocker usage then the two week period of withdrawal should be considered a minimum - a longer period of withdrawal might be required if a patient is on a high dose beta blocker/has significant co-morbidities such as coronary heart disease
      • if beta blocker therapy is being withdrawn then it seems prudent to regularly monitor pulse and blood pressure of these patients during the withdrawal of beta blocker therapy

Reference:

1. Nattel S et al. Mechanism of Propranolol Withdrawal Phenomena.Circulation 1979;59:1158-1164
2. Wallace AW et al. Association of the pattern of use of perioperative beta-blockade and postoperative mortality. Anesthesiology. 2010 Oct;113(4):794-805.