Atenolol withdrawal how long

Abrupt withdrawal may cause rebound hypertension, tachycardia, arrhythmia or angina. These events may be physiological withdrawal reactions or an exacerbation of the underlying condition. The decision to stop a statin is based on an assessment of individual benefits and risks. For example, stopping may be justified in a person at relatively low risk of a cardiovascular event, who is also poorly compliant or experiencing troublesome adverse effects.

In most cases statins can be stopped without the need for tapering. Statins should not be stopped in patients admitted with or with a history of cardiovascular events including acute coronary syndrome, myocardial infarction and stroke. In older people taking warfarin, low initial and maintenance dosages are recommended e. Some clinicians tail off long-term treatment over several weeks but the need for this is unclear. It is possible to stop abruptly rather than taper Table 4. Risks associated with NSAIDs usually relate to declining renal function in the older age group and adverse gastrointestinal effects.

NSAIDs may also reduce the effectiveness of antihypertensive therapy. Some patients may tolerate abrupt discontinuation but tapering the dose allows for other analgesics to be introduced or increased Table 5. Many people remain on acid suppressants despite there being no ongoing clinical indication e. It is often possible to maintain symptom control on a lower dose or on an as needed basis rather than on long term high dose maintenance therapy.

Tapering the dose of an acid suppressant both PPIs and H 2 RAs is recommended because of the risk of rebound hypersecretion of gastric acid Table 6. Following discontinuance of omeprazole therapy, gastric acid secretion returns to baseline over a three to five day period. The beneficial effects e. Beneficial effects on BMD persist after stopping the drug. For correspondence regarding stopping alendronate therapy, see "Correspondence: Guidance for stopping alendronate" , BPJ 46 September, Tapering may not be required for some patients who have received low to moderate doses e.

Withdrawal should not be abrupt for the majority of patients who have been taking systemic corticosteroids for more than three weeks. These patients should generally have their corticosteroid slowly tapered to allow the HPA axis to recover over weeks or months.

An increase in dose may also be required during periods of stress e. There are several methods for tapering oral corticosteroids Table 7. The majority of patients respond initially to levodopa and its use improves the quality of life. After two years or more, benefit is reduced as the disease progresses and late complications emerge. If antiparkinsonian drug therapy is reduced abruptly, or discontinued, a symptom complex resembling neuroleptic malignant syndrome can occur Table 8.

Follow us on facebook. Decision support for health professionals ». South Island general practice support ». Practice acquisition and careers in health ». Click here to register ». Forgot your login? Login to my bpac. Remember me. A practical guide to stopping medicines in older people The majority of older people who require drug therapy take multiple medicines.

In this article Polypharmacy increases the risk of adverse effects and medicine interactions How do you decide which medicines can be stopped? What are the likely consequences of stopping medicines? How to stop medicines Specific guidance on stopping medicines References In this article.

Key concepts The majority of older people who require drug therapy take multiple medicines Withdrawing medicines may be the best clinical decision Factors to consider when deciding if a medicine can be stopped include the wishes of the patient, clinical indication and benefit, appropriateness, duration of use, adherence and the prescribing cascade Only stop or reduce one medicine at a time Tapering the dose helps reduce the likelihood of an adverse withdrawal event.

Polypharmacy increases the risk of adverse effects and medicine interactions The majority of older people have more than one medical condition, more than one prescriber and take more than one medicine.

How do you decide which medicines can be stopped? Factors to consider when deciding if a medicine can be stopped include: The wishes of the patient Clinical indication and benefit Appropriateness Duration of use Adherence The prescribing cascade. Medicines can be grouped as: Those that keep the patient well and improve day-to-day quality of life e.

In some cases, if these medicines are stopped, the patient may become ill or unable to function. However, some drugs may be able to be stepped down, stopped or used on an as required basis prn e.

Those that are used for the prevention of illness in the future e. A decision about whether to stop medicines such as these should include consideration of the risks and benefits of treatment for that particular patient, the length of time required for benefit and the life expectancy of the patient. The wishes of the patient The majority of people who take medicines would prefer not to, or at least to take only those that are really needed.

Clinical indication Check that there is still a valid clinical indication and ongoing clinical benefit for each medicine. Appropriateness Check that the medicine is appropriate for use in an older person see below. Benzodiazepines, which can cause excessive sedation and increase the risk of falls.

Dextropropoxyphene, which can cause confusion and excessive sedation particularly in older people. Evidence shows that it is no more effective for pain than regular paracetamol use. When considering any new medicine for an older person, check if it is appropriate by considering the following questions: Adapted from Holmes, 2 Is there an indication for the drug?

Is the medicine effective for the condition? Are there clinically significant drug-drug interactions? Is there unnecessary duplication with other medicines? Is the likely duration of therapy known and acceptable to both doctor and patient?

Will the patient take the medicine — what are the likely adverse effects, is the dose correct, are the directions practical? Is this medicine the least expensive alternative compared with others of equal usefulness? Duration of use Check how long the patient has been on the medicine. Adherence Check if the patient is taking all of their prescribed medicines.

The prescribing cascade When a patient presents with new symptoms, consider an adverse medicine reaction as a possible cause. Amitriptyline has anticholinergic actions which can cause urinary retention leading to overflow incontinence.

If this is not recognised, oxybutynin may be prescribed, which aggravates the incontinence because it also has anticholinergic actions. In addition, the patient then becomes constipated and a laxative is prescribed. One medicine has led to the use of three others. Stopping the amitriptyline and finding an alternative medicine for the pain may be the best action A patient taking a calcium channel blocker presents with ankle swelling.

Avoid prescribing a diuretic as they are not effective in this situation. How a medicine is stopped is likely to alter the risk of withdrawal symptoms For some classes of medicine e.

For example, abrupt discontinuation of: A beta-blocker may result in rebound tachycardia, an increase in blood pressure and, in some circumstances, cardiac ischaemia. An antidepressant may result in withdrawal symptoms that are similar to those of depression, which may make it difficult to determine whether the original depression has returned, or if the symptoms are a result of the abrupt discontinuation. A PPI is more likely to result in rebound hyperacidity. How to stop medicines Take a stepwise approach to stopping medicines A four step process can be used when stopping medicines: 13 Recognise the need to stop Reduce or stop one medicine at a time Consider if the medicine can be stopped abruptly or should be tapered Check for benefit or harm after each medicine has been stopped Recognise the need to stop a medicine When the patient presents for a renewal of medicine ask if they have any new symptoms including adverse effects or any concerns about their medicine.

A general guide to tapering medicine: Halve the dose. At the next scheduled visit review progress, then either: Maintain at half dose Continue to taper e. Specific guidance on stopping medicines Antidepressants Benzodiazepines Antihypertensives Statins Warfarin NSAIDS Acid suppressants Bisphosphonates Oral Corticosteroids Antiparkinson agents Antidepressants Antidepressants should be tapered rather than stopped abruptly, to reduce the risk of developing a discontinuation syndrome and to allow time to assess the possible re-emergence of depressive symptoms Table 1.

Antidepressant Discontinuation Syndrome 16,22 Antidepressant discontinuation syndrome can occur with rapid discontinuation of any antidepressant. Symptoms are variable. Symptoms are likely to appear within one week of rapid dose reduction or abrupt discontinuation of an antidepressant.

Symptoms are often mild and short lived and resolve without treatment in about ten days. For patients with more severe symptoms the pre-reduction dose may need to be restarted which usually results in resolution of symptoms within 24 hours.

Subsequent tapering then needs to be at a slower rate. Table 1 : A guide to discontinuing antidepressants General tapering guide Withdrawal effects An antidepressant should not be stopped abruptly if it has been taken for six weeks or more The dose should be reduced gradually over at least four weeks, or longer if withdrawal symptoms emerge 17 Wide range of symptoms including anxiety, gastrointestinal disturbance, headache, insomnia, irritability, malaise, myalgia, recurrence of depression Specific classes Withdrawal effects SSRIs and venlafaxine Taper slowly over several weeks or months e.

There may be a delay before symptoms present for patients on higher doses of fluoxetine because of the longer half-life. Discontinuation syndrome appears to occur more frequently with paroxetine and venlafaxine. This may partly be due to the shorter half-life of these drugs. TCAs Tricyclic and related antidepressants e. MAOIs Withdraw slowly Neuropsychiatric symptoms may be more prominent and include severe anxiety, agitation, altered sleep, hallucinations, delirium and paranoid psychosis Benzodiazepines Regular and prolonged use of hypnotics should be avoided because of the risk of tolerance to effects, dependence and an increased risk of adverse events.

Table 2 : A guide to discontinuing benzodiazepines Tapering guide Withdrawal effects Slowly taper the dose in steps of approximately one-eighth of the daily dose every two weeks 18 If withdrawal symptoms occur, maintain at the current dose until symptoms settle and then continue to taper, usually at a slower rate Wide range of symptoms including anxiety, mood changes, insomnia, palpitations, tremor, headache, gastrointestinal disturbance, muscle stiffness and spasms Benzodiazepine withdrawal syndrome Alternative withdrawal method 18 Dose equivalence 15,18,20 Transfer patient to an equivalent daily dose of diazepam, preferably taken at night Reduce the dose of diazepam every two to three weeks by 2 or 2.

If withdrawal symptoms occur, maintain this dose until there is improvement. Continue to reduce the dose, if necessary by smaller amounts. It is better to reduce too slowly rather than too quickly. Stop diazepam completely. The withdrawal period may vary from about four weeks to more than one year. Antihypertensives Beta-blockers are the cardiovascular medicine most often associated with adverse withdrawal events.

Table 3 : A guide to discontinuing antihypertensives 18 General tapering guide Withdrawal effects Most antihypertensives should be tapered.

Taper dose at approximately monthly intervals, over three to six months. Wide range depending on the specific medicine and the condition being treated. May include ankle oedema, weight gain, headache, tachycardia, increased blood pressure, worsening heart failure or angina, myocardial infarction.

Specific classes Withdrawal effects Beta-Blockers Gradual dose reduction necessary Sudden withdrawal may cause or exacerbate angina Calcium channel blockers Consider gradual reduction Sudden withdrawal may exacerbate angina Thiazides It may not be practical to cut tablets so either stop or consider alternate day dosing initially then twice weekly dosing Possible exacerbation of the underlying condition Angiotensin-converting enzyme inhibitors Consider gradual reduction Possible exacerbation of the underlying condition.

Statins The decision to stop a statin is based on an assessment of individual benefits and risks. Warfarin In older people taking warfarin, low initial and maintenance dosages are recommended e.

Table 4 : A guide to discontinuing warfarin Tapering guide Withdrawal effects Stop abruptly or Taper over several weeks A rebound hypercoagulable state with a risk of thrombosis, has been reported in some patients but this can occur even if the dose is tapered and may reflect the initial pro-thrombotic state for which treatment was started Table 5 : A guide to discontinuing NSAIDs Tapering guide Withdrawal effects Consider prn use or regular use at a lower dose Can be stopped abruptly or Halve the dose for two to four weeks then stop Review the need for gastric protection therapy i.

Acid suppressants Many people remain on acid suppressants despite there being no ongoing clinical indication e. Table 6 : A guide to discontinuing acid suppressants General tapering guide Withdrawal effects Halve the dose for four to eight weeks then stop or step down to a less potent agent Consider providing an antacid for dyspepsia symptoms Recurrence of oesophagitis and indigestion symptoms Specific medicines Withdrawal effects Proton pump inhibitors PPI Consider alternate day dosing.

Capsules cannot be halved. Bisphosphonates The beneficial effects e. Alendronate can be stopped abruptly without the need for tapering. Table 7 : A guide to discontinuing oral corticosteroids Tapering guide Comments For patients who have been on corticosteroid treatment for three weeks or longer reduce the dose, e.

Once the dose has reached 5—10 mg daily, reduce the dose more slowly, e. Reduce more slowly initially if it is likely that the disease will relapse e. Antiparkinson agents The majority of patients respond initially to levodopa and its use improves the quality of life. Table 8 : A guide to discontinuing antiparkinsonian medicines Tapering guide Withdrawal effects Antiparkinsonian medicines should not be stopped abruptly as there is a small risk of neuroleptic malignant syndrome 18 Reduce the dose gradually over about four weeks Sinemet CR tablets are scored and may be administered as half tablets Hypotension, psychosis, pulmonary embolism, rigidity, tremor A symptom complex resembling the neuroleptic malignant syndrome may occur.

Symptoms include muscular rigidity, elevated body temperature, mental changes, diaphoresis, tachycardia, and tachypnea. There may be an increase in serum creatine kinase concentration. Measuring the quality of medicine use in older adults. J Am Geriatr Soc ; Reconsidering medicine appropriateness for patients late in life. Arch Intern Med ; Dilemmas in prescribing for elderly people. Why is it difficult? BPJ ; Prioritizing and stopping prescription medicines.

CMAJ ; 8 Holmes HM. Rational prescribing for patients with a reduced life expectancy. Clin Pharm Ther ;85 1 Managing comorbidities in patients at the end of life. BMJ ; Potentially inappropriate medicine use in the community-dwelling elderly. JAMA ; 22 Inappropriate prescribing for elderly americans in a large outpatient population.

Arch Int Med ; 15 Dextropropoxyphene — review concludes risk-benefit balance unfavourable. Prescriber Update ;31 1 Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol ;68 6 Inappropriate drug prescribing in older adults: the updated Beers criteria — a population-based cohort study. Br J Clin Pharmacol ;60 2 Medicine withdrawal trials in people aged 65 years and older: A systematic review. Drugs Aging ;25 12 Discontinuing medicines: a novel approach for revising the prescribing stage of the medicine-use process.

J Am Geriatr Soc ; 56 10 JAMA ;— Therapeutic Guidelines: Psychotropic. Version 6. Take the atenolol packet or leaflet inside it, plus any remaining medicine, with you. Like all medicines, atenolol can cause side effects in some people, but many people have no side effects or only minor ones. These common side effects happen in more than 1 in people. They're usually mild and short-lived. Talk to your doctor or pharmacist if these side effects bother you or last more than a few days:. It happens rarely, but some people have serious side effects when taking atenolol.

In rare cases, atenolol may cause a serious allergic reaction anaphylaxis. These are not all the side effects of atenolol. For a full list, see the leaflet inside your medicine packet. If you're trying to get pregnant or already pregnant, talk to your doctor about the benefits and possible harms of taking atenolol.

There may be other medicines that are safer for you. For more information about how atenolol can affect you and your baby during pregnancy, visit the best use of medicines in pregnancy BUMPS website. If your doctor or health visitor says that your baby's healthy, it's OK to take atenolol while breastfeeding.

Atenolol passes into breast milk in small amounts, and it's unlikely to cause any side effects in your baby. It's important to treat your high blood pressure to keep you well. Breastfeeding will also benefit both you and your baby. If your baby's not feeding as well as usual or seems unusually sleepy, or you have any other concerns about them, talk to your doctor or health visitor. There's very little information about taking herbal remedies and supplements with atenolol.

Tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements. Like other beta blockers, atenolol works by changing the way your body responds to some nerve impulses, including in the heart. It slows down your heart rate and makes it easier for your heart to pump blood around your body. It may work by relaxing the blood vessels involved or by reducing activity in the visual cortex.

This is the part of the brain where migraines are believed to start. Atenolol starts to work after about 3 hours to reduce high blood pressure, but it can take up to 2 weeks to reach its full effect. You may not feel any different when you take atenolol for high blood pressure, but this does not mean it's not working.

It's important to keep taking your medicine. For migraines, it may take several weeks for atenolol to start making a real difference, so keep taking it. For heart conditions or high blood pressure - treatment is usually long term and may be for the rest of your life.

For migraines - treatment can last for several months or years, depending on how bad your symptoms are. If you're taking it for a heart condition or to prevent migraines, it works best when you take it long term. You'll need to have your blood pressure checked regularly if you're taking atenolol for a long time for migraines. If you're bothered by side effects, your doctor may be able to prescribe a different medicine instead. If you stop taking atenolol, it'll take about 1 to 2 days for it to be completely out of your body.

Atenolol works as well as other beta blockers for reducing blood pressure. Other beta blockers, like propranolol , work on your heart and affect other parts of your body, too. There are lots of other medicines to lower your blood pressure and treat chest pain. Beta blockers are not usually the first choice treatment for high blood pressure.

If you're under 55, you'll usually be offered an ACE inhibitor or an angiotensin receptor blocker. If you're 55 or older, or you're any age and of African Caribbean or black African origin, you'll usually be offered a calcium channel blocker. Sometimes you may have to try other blood pressure-lowering medicines if you get side effects. Many people need to take a combination of different blood pressure-lowering tablets.

Atenolol, metoprolol , propranolol and nadolol are all beta blockers , and they work well in preventing migraines. But most doctors prescribe propranolol.

There are some other medicines that are known to prevent migraines, but they're not officially approved in the UK. They include amitriptyline , sodium valproate and gabapentin , and may have different side effects.

Topiramate can also be used to prevent migraines. But topiramate has not been officially approved for migraine for children under the age of Tell your doctor that you're taking atenolol if you're going to be put to sleep using general anaesthetic or you're having any kind of major operation.

Your doctor may advise you to stop taking atenolol for 24 hours before surgery. This is because atenolol can lower your blood pressure too much when it's combined with some anaesthetics. Drinking alcohol can increase the blood pressure-lowering effect of atenolol, which can make you feel dizzy or lightheaded. During the first few days of taking atenolol or after an increase in your dose, it's best to stop drinking alcohol until you see how the medicine affects you.

If you find atenolol makes you feel dizzy, it's best to stop drinking alcohol. Eating a healthy, balanced diet can help if you have high blood pressure or another heart condition.

But some types of hormonal methods of contraception, like the combined pill and contraceptive patch , are not usually recommended for women with high blood pressure. It's unlikely that atenolol affects fertility in men or women. But there's not enough evidence to say for certain. If you're trying for a baby or having problems getting pregnant while on atenolol, speak to your doctor.

Some people on atenolol say their sex drive goes down, and some men find they cannot get an erection. But this is not a common side effect and there's not enough evidence to say for sure that atenolol is causing it. You do not need to stop playing sports if you take atenolol. But do not push yourself too much. Regular exercise is good for you because it lowers blood pressure by keeping your heart and blood vessels in good condition.

Be aware, though, that in some sports atenolol is not allowed if you're competing at a high level. Atenolol can make some people feel dizzy, especially when you first start taking it or after taking a bigger dose. If this happens to you, do not drive a car, ride a bike, or use tools or machinery until you feel better. If you have heart problems, you can boost the health of your heart by making some key lifestyle changes.

These will also help if you have high blood pressure. There are a number of things you can do to help prevent migraines. This includes working out what things trigger an attack so you can avoid them.

Page last reviewed: 19 March Next review due: 19 March Atenolol On this page About atenolol Key facts Who can and cannot take atenolol How and when to take it Side effects How to cope with side effects Pregnancy and breastfeeding Cautions with other medicines Common questions. About atenolol Atenolol belongs to a group of medicines called beta blockers. This medicine is only available on prescription. Help us improve our website Can you answer a quick question about your visit today? Atenolol slows down your heart rate and makes it easier for your heart to pump blood around your body.

It can make you feel dizzy, sick or tired, or give you constipation or diarrhoea. These side effects are usually mild and short-lived. Your very first dose of atenolol may make you feel dizzy, so take it at bedtime.

After that, if you do not feel dizzy, you can take it in the morning. Atenolol is known by the brand name Tenormin. Other brand names include Tenif for atenolol mixed with nifedipine and Co-tenidone atenolol mixed with chlortalidone.

To make sure it's safe for you, tell your doctor before starting atenolol if you have: had an allergic reaction to atenolol or any other medicine in the past low blood pressure or a slow heart rate serious blood circulation problems in your limbs such as Raynaud's phenomenon , which may make your fingers and toes tingle or turn pale or blue metabolic acidosis - when there's too much acid in your blood lung disease or asthma Tell your doctor if you're trying to get pregnant, are already pregnant or breastfeeding.

You'll usually take atenolol once or twice a day. It's a good idea to leave 10 to 12 hours between doses if you can. Dosage How much you take depends on why you need atenolol. How to take it Atenolol does not usually upset your tummy, so you can take it with or without food.

Swallow the tablets whole with a drink of water. What if I forget to take it? If you often forget doses, it may help to set an alarm to remind you. What if I take too much? Side effects often improve as your body gets used to the medicine. Common side effects These common side effects happen in more than 1 in people.

Talk to your doctor or pharmacist if these side effects bother you or last more than a few days: feeling sleepy, tired or dizzy cold fingers or toes feeling sick nausea diarrhoea constipation Serious side effects It happens rarely, but some people have serious side effects when taking atenolol. Tell a doctor straight away if you have: shortness of breath with a cough that gets worse when you exercise like walking up stairs , swollen ankles or legs, chest pain, or an irregular heartbeat - these can be signs of heart problems trouble breathing, cold sweats and sudden, sharp chest pain that gets worse when you cough or take deep breaths - these can be signs of lung problems a fast heart rate, a high temperature, trembling and confusion - these can be signs of a thyroid problem Serious allergic reaction In rare cases, atenolol may cause a serious allergic reaction anaphylaxis.

Information: You can report any suspected side effect using the Yellow Card safety scheme. Visit Yellow Card for further information. What to do about: feeling sleepy, tired or dizzy - as your body gets used to atenolol, these side effects should wear off.

If atenolol makes you feel dizzy, sit or lie down until you feel better. Do not drive or operate machinery until you feel OK again. Try to avoid alcohol as it'll make you feel worse. Do not smoke or have drinks with caffeine in - this can make your blood vessels narrower and further restrict blood flow to your hands and feet.

Try wearing mittens they're warmer than gloves and warm socks. Do not wear tight watches or bracelets. It might help to take your atenolol after a meal or snack.