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Emphyrio

Tapering Beta Blockers or Alpha Blockers

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Emphyrio

Hello,

 

For the past 3-4 weeks I've been taking 160mg of propranolol for agitation/restlessness/akathisia (whatever it is) - 80mg slow release every morning and night. It's really just a short-term means of managing some (mainly physical) symptoms while I stabilise. I'm tolerating it well so far, though I don't particularly want to take it long-term.

 

My question therefore is - how should one taper off beta blockers? I know that they should be tapered because of the risk of rebound palpitations, hypertension or tremor, but as far as I'm aware nobody has ever experienced long-term/protracted withdrawals from beta blockers, unlike benzos, antidepressants or antipsychotics.

 

What is a good tapering schedule?

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lexhex

Because beta blockers have a direct effect on the heart and the upregulation of beta adrenergic receptors, you should never taper them without careful planning with your doctor. You could end up with serious heart rhythm issues and runaway hypertension. Best to get professional advice on this one.

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Laqiya

I have friend who is on Prazosin to control blood pressure and considering reducing the dose with doctor's permission soon. Since it is an alpha blocker wondering if a liquid micro taper would be better instead of a faster taper. Not sure what kind of taper would be suitable for this drug though. Would be grateful for any advice/tips for tapering this drug, thanks.

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Altostrata

Please see above.

 

Beta blockers and alpha blockers also require slow tapering, 10% reductions at a time based on the last dosage (the amount of the reduction keeps getting smaller). Taper should be slow enough not to trigger blood pressure rebound increases.

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Laqiya

Alto,

 

Sorry wasn’t aware that that there was a thread on alpha blockers.

 

And if you’re really sensitive to tapering changes, based on symptoms, I suppose a micro taper would be more suitable to be on the safe side.

 

Thank you so much.

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Emphyrio

Thanks for the replies. Was just wondering though whether there have been any documented cases of protracted withdrawal from beta blockers or other non-psychiatric medications?

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Meimeiquest

I took it for about two months, took six months to taper, and at least two months, maybe more, for my heart "thudding" to stop completely. BUT I think food allergies were bothering me, and I was diagnosed with copper overload by orthomolecular docs, which reportedly causes "racing heartbeat. ". Since all that, I had a stress test that felt normal to me and the EKG machine. Taurine was a big help in the process, there is a thread on it

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Altostrata

I combined threads into this topic.

 

It's very important to taper off drugs that affect heart rhythm or blood pressure. Quitting suddenly can make you very sick.

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nz11

 

 

It's very important to taper off drugs that affect heart rhythm or blood pressure. Quitting suddenly can make you very sick.

 

What is the priority of taper  importance when a cocktail contains a beta blocker ?

 

ie where does a beta blocker sit in the tapering pecking order?

 

eg popranolol (inderal)

 

After or before, the ad?  the benzo? the antipsychotic? the anticonvulsant ?

At the end of the que? At the beginning?

 

Are beta blockers actually considered psych drugs? Or pushed off label as such since it appears they were first developed for the treatment of certain heart conditions and hypertension.

 
Bit confused on this one.

 

.

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Altostrata

Psychiatrists and other doctors often prescribe beta blockers as anxiety drugs.

 

They are "brakes" and should be tapered when more activating drugs are removed. If you're off an antidepressant, you need to assess how you're feeling to decide whether to go off the beta blocker or antipsychotic.

 

If the beta blocker was prescribed to counter "anxiety" from the antidepressant, you don't need the beta blocker any more. If the antipsychotic was prescribed for sleep, you may wish to taper it after the beta blocker. In my opinion, lamotrigine and other anticonvulsants should be tapered last as they tend to dampen hyper-reactivity from withdrawal of any type of drug.

 

However, the person's current state, symptoms, and reactions determine what to do next. There's no simple cookbook to follow.

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SelmaLady

I seem to have a paradoxical reaction to the Clonidine I have been taking over the past 2 1/2 years prescribed initially for akathisia.  I had planned on removing it once I was off the Doxepin that I'm taking, but last November the supplier I was using (Qualitest) ran out of Clonidine at the dosage I am taking (0.1mg morning and evening) and my pharmacy gave me another brand of generic.   My husband and I tried to slowly taper over from the original brand to the new brand but within a couple of weeks, my B/P went way up, fluctuating from a morning reading of about 140/95 or so to 175/110 in the evening.  We increased the new brand but after taking it, my B/P rose even higher.  

After talking to a couple of ladies who had that happen to them, having the B/P rise after taking a beta blocker (I know that Clonidine is a type of alpha blocker) I decided that I was mostly likely having a paradoxical reaction to that brand.  I called Qualitest and was told that they had restocked Clonidine 0.1mg so I contacted my pharmacy and they reordered for me.  But even after returning to the original brand at the original dose, my B/P was VERY high after taking it too.  So we took a 20% cut in the morning dose and my B/P was much lower after taking it.

We have slowly been reducing by grains (my husband has a scale and is weighing each tablet) both the morning and the evening pills,  holding when I'm symptomatic from the mess I was already in!  I took my B/P randomly over the past few weeks and it seemed to be moving down, especially in the morning from the reduced tab.  I had a B/P of 145/92 in the doctor's office last Thursday but then yesterday I felt quite ill and so last night after taking the Clonidine, my B/P was back to 175/102.  It has been 10 days since my last tiny cut.

I am waking up in the middle of the night again after having returned to normal sleep from the cuts and have a headache and nausea and agitation.  We're planning on cutting 3 grains from tonight's dose.  This is a hard call and we're just having to assume that I am paradoxical but I never had high B/P before being given the Clonidine and in fact, my B/P was good the whole time I've been on it until the problem with the brands and the attempt to switch over.   But I am wanting to be free of the Clonidine if I am so sensitive to a brand change as I'm quite certain this will come up again. 

Since I am reacting to dosing, what rate should I reduce at?  This is all quite worrisome to say the least.

 

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SelmaLady

Well, I just read something on RXList that really showed me what's going on.  Apparently TCA's (Which Doxepin is) and Clonidine should NEVER be given together as the combo can cause high blood pressure readings:  "Dangerous elevations in blood pressure may occur if TCA are combined with clonidine (Catapres, Catapres-TTS)."  Swell.  I think that the upset with the different brands set this off big time so I guess all I can do is a steady and consistent taper of the Clonidine.  I'm wondering tho if I can't taper the Doxepin in micro cuts at the same time?

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Altostrata

Tapering two drugs at once can be confusing; if you get a bad reaction, which one is causing it? Which do you updose?

 

The Drug Interactions Checker http://www.drugs.com/drug_interactions.htmlis a fairly good source for identifying symptoms that might be related to drug combinations. Doctors and pharmacists are supposed to use something similar, but often skip that step.

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SelmaLady

Tapering two drugs at once can be confusing; if you get a bad reaction, which one is causing it? Which do you updose?

 

The Drug Interactions Checker http://www.drugs.com/drug_interactions.htmlis a fairly good source for identifying symptoms that might be related to drug combinations. Doctors and pharmacists are supposed to use something similar, but often skip that step.

 

Yeah, I know.  I guess I'll just stick with tapering the Clonidine as that has less ramifications than the Doxepin.  Both are so toxic .. 

 

My Nurse Practitioner who sees me 2x a year never comments on the combo of drugs I'm taking.  She said something this last time about being given the Clonidine to help with the Doxepin being too activating (she was not the original prescriber) ...  Plus of course, the Zoloft thrown into the mix...  Just is so unbelievable that neither doctors or pharmacists take a look at what's being rx'd together.

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SelmaLady

Tapering two drugs at once can be confusing; if you get a bad reaction, which one is causing it? Which do you updose?

 

The Drug Interactions Checker http://www.drugs.com/drug_interactions.htmlis a fairly good source for identifying symptoms that might be related to drug combinations. Doctors and pharmacists are supposed to use something similar, but often skip that step.

 

I did check on the interactions of Doxepin and Clonidine again and after further reading found out that they decrease each others action.   I'm thinking that it has to do with norepinephrine ---Doxepin raising it and Clonidine lowering it.  Ideally, you would taper together but can't do that.  So..... I'm going to micro raise the Clonidine again and see if there's any change in the B/P because it is scary high now.  I'm hoping that my system will allow me to raise my dose back up to where it was and lower the B/P back to what it was before the fiasco with the Clonidine supplier.   As a side note, my husband spoke with a pharmacist at our mail order/on line pharmacy (Express Scripts) who assured him that there is NO difference between brands of generic Clonidine and that I shouldn't have had any problems....my, I guess I broke the rules! 

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Reflex

Please see above.

 

Beta blockers and alpha blockers also require slow tapering, 10% reductions at a time based on the last dosage (the amount of the reduction keeps getting smaller). Taper should be slow enough not to trigger blood pressure rebound increases.

My daughter has taken atenolol (beta blocker ) for migraine for the last three years. She wants to try without now that all the pressure of exams are over. What would you suggest with regards to tapering plan?

Does a liquid version exist?

 

I'm so annoyed with myself for taking her to the doctors initially and for being given a drug which she has now to taper from.

It's one thing for me as an adult to be placed on drugs but another for a 15 year old.

Any help welcome please

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mammaP

Hi Reflex, atenolol needs careful tapering and is available in a liquid that is 25mg per ml. It is better for tapering because it can be diluted to get smaller decreases. You might need to be polite but assertive with your GP to get the liquid, they often recommend tapers that are far too fast. 

 

You could taper by 10% of the previous dose with 3 weeks between drops. It is easier than anti depressants but still needs tapering because it affects blood pressure and could lead to a spike by cutting too much at once.  It will take time but is better in the long term, going too fast could end up being given more drugs to counter the withdrawal.  

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Barbarannamated

My 91yo father's doc just CTd him from metoprolol 20mg bid after DECADES on it.  His BP has been running low and I agree that metoprolol should be discontinued, but not abruptly.   I'm battling home health nurse and his doctor who say they'll monitor his BP.   Of course, my dad refuses to go against doctor orders.  

 

The doc already DCd (cold turkey) Norvasc (calcium channel blocker) and Lasix within the past 2 month.  

 

Am I overreacting?   Any suggestions welcome.  

 

 

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Altostrata

You need to either educate the doc or find a new doc.

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lxjuice

I'm pretty confident in saying alpha blockers don't need withdrawal periods. And I should point out that clonidine is NOT an alpha blocker, despite some websites grouping it with them. That stuff absolutely needs a taper.

There is no rebound sympatholytic activity with discontinuation of terazosin for several weeks [1]. And there is no rebound noted with discontinuation of prazosin for a short period, after it was taken for several months [2]. Some of the PTSD/prazosin studies looked at skipped doses [3] and found that nightmares and symptoms returned. Now they weren't specifically looking for whether they would get worse vs pre-treatment but some state return of symptoms, some state return to pre-treatment levels, but none worse. Also neither hypertension or CHF study noted rebound anxiety or anything like that, which is probably more important because they would more clearly indicate a long term psychiatric change of baseline than the PTSD studies, who well... already have PTSD. But alpha blockers do stop working at least for some so the implication is that 1) the alpha 1 receptor desensitizes to the drug in a way that isn't upregulation and 2) there isn't really a large hormonal change induced by stopping these drugs like with antidepressants or these studies would have been a lot more eventful (and this was actually measured in [1]).

 

Although it's useful to do a taper when using for PTSD because of rebound symptoms even if they are only temporary once the trauma has been processed, there isn't any sense in tapering it like an antidepressant at 10% per month.

 

Granted, they're not some of the more common drugs people come off over here... but there it is.

 

References: [1] https://www.ncbi.nlm.nih.gov/pubmed/2872805

[2] https://www.ncbi.nlm.nih.gov/pubmed/7223594

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538493/

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