How to safely come off beta blockers
Channel: York Cardiology
Date: 2021-05-04

A lot of people have contacted me and asked me as to how to safely stop beta blockers and therefore  I thought I would do a quick video around this subject.

Before I start it is important to say that please do not try and alter your dosage without speaking with you health care provider as he will know about your unique clinical situation and all I am doing in this video is just giving general information.

Beta Blockers are one of the commonest classes of medications that we use in cardiology and often serves as a jack of all trades. They basically blunt sympathetic activity and by doing so, have a multitude of potentially beneficial effects such as reducing heart rate, reducing blood pressure, making the heart less irritable, reducing the demands on the heart and increasing the time for the heart to fill with blood do that the heart is able to contract more effectively. In some situations they make people feel better I.e improve quality of life. In other situations, they may actually have a prognosis modifying role.

Let me give you some examples.

Beta blockers can be used to control blood pressure. Here they don’t necessarily make patients feel better may have a prognosis modifying role (albeit a weak one).

Beta blockers can be used as a treatment for heart failure. Here they make people feel better and have a very significant impact on improving lifespan

Beta blockers can be used for heart rhythm disturbances (ectopics/AF/SVT/VT) and her they may make the patient feel better and in some heart rhythm disturbances may also have a prognosis modifying role

Beta blockers can be used to treat angina and prolong life after a heart attack so against they may improve quality and quantity of life.

Sometimes beta blockers are used in a purely symptom control role such as for controlling anxiety or benign ectopics in people with normal hearts

So if you are taking beta blockers it is always worth asking why you take them. Is it because they make you feel better or is it because they in some way are being used for their prognosis modifying effects? This is important because if they have a prognosis modifying role you may decide you just want to remain on them 

Acute, abrupt withdrawal of beta blockers has been shown in many case reports to be associated with an increased risk of morbidity and mortality. This is mainly seen in patients who were taking the beta blocker for angina due to significant coronary disease and in a few of these patients, stopping the beta blocker was associated with more angina and even development of heart attacks. Similarly there have been case reports of patients who were taking beta blockers to control dangerous heart rhythm disturbncaces and when the beta blocker was abruptly stopped it led to precipitation of ventricular dysrhythmias and even in some cases death. There have also been reports of heart failure status worsening and blood pressure going up excessively. This is termed as Acute beta blocker withdrawal syndrome.

Why does it happen?
It is believed that withdrawal effects happen because if increased sympathetic activity which is probably because of Beta receptor up regulation during the period of beta blockade. Upregulation is a well recognised phenomenon where the receptors that are being blocked become more sensitive and responsive to circulating adrenaline. It is believed that receptors take 24-36 hours to down regulate when the blockade is removed. So if you stop the beta blocker abruptly and it doesn’t stay in the body long (and how long it hangs around in the body depends on that beta blockers half life) then there may be a period where you have receptors which are significantly more sensitive to the effects of the adrenaline and this can then trigger this withdrawal syndrome. What this means is that the withdrawal syndrome is far more likely with short acting beta blockers or those beta blockers where you have to take 2 or 3 doses in day because they will have a much shorter half life. Beta blockers that have a lon half life will stay in the body for much longer and therefore will allow that time that is needed for the beta receipts to down regulate.

So if you are taking a short acting beta blocker I.e propranolol, metoprolol, carvedilol etc, it is best to be more cautious about reducing the dose.In such cases I would suggest taking the usual dose once daily for a week, then every other day for a week and then stop.

If you are taking a long acting beta blocker eg Atenolol, Bisoprolol etc , then take half the usual dose for a week, then half the the usual dose every other day for a week and then stop.

As I say it is very important that you only alter your dosages if sanctioned and supervised by your own doctor as it may in some patients have dangerous consequences.