Propranolol withdrawal

[[Ho...]]

Hi all. I would like to start a thread on propranolol withdrawal. I’m hope 76 and I finished up a 3 plus year valium taper in March 2019. I do have some protracted symptoms, but overall have done well, and have been back to normal functioning life. Recently I have run into some troubles. I had a problem with my near vision and was found to have malalignment of my eyes. It set off a huge cascade of nervous system overstimulation as it was taking a while to get the vision problems treated. I kept going through many pairs of glasses. We are finally on the right track with the vision but my anxiety level got so bad that I ended up on propranolol. I had taken propranolol immediate release 10 mg daily during my benzodiazepine taper without any problems, and I fairly easily tapered it off after the valium taper was over. This time I started requiring more and more propranolol, and it seemed that I would get an inter-does withdrawal or rebound symptoms 4 hours after the dose within the first week of using it. I moved to extended release and landed on 60 mg twice a day. This is quite a bit higher dose than I was on before and it’s making me sick. I am working on a way to taper off. There’s no way to compound or cut the extended release capsules so I’m using a compounding pharmacy that will use immediate release propranolol powder and then add in a slow release agent that supposedly last Ms 24 hours although I’m suspect about this. I am planning on dosing the compounded propranolol 40 mg three times a day just to cover any potential breakthrough symptoms and then tapering from there with a conservative cut and hold taper.. I’m really hopeful that it works. I would love to hear any of your experiences with propranolol withdrawal, especially if you were on propranolol ER and how you did it. When did your symptoms peak after each dose reduction? to complicate matters I think I’m also having a flareup benzodiazepine symptoms which is making this much harder.
 

[[An...]]

Hi @[Ho...],

I would just like to welcome you to BB. I don't however have any clue on how to safely taper the propranolol. Have you discussed this with your prescribing doctor?

Congrats on getting off the valium in 2019. Just curious...what SXs are you having from the propranolol  that makes you want to stop taking it?

[[Ho...]]

7 hours ago, [[A...] said:

Hi @[Ho...],

I would just like to welcome you to BB. I don't however have any clue on how to safely taper the propranolol. Have you discussed this with your prescribing doctor?

Congrats on getting off the valium in 2019. Just curious...what SXs are you having from the propranolol  that makes you want to stop taking it?

Thanks Antibenzo. I don’t feel well on propranolol at all. I think the dose is too high for my body, but I was getting rebound symptoms (elevated heart rate, shaking, severe anxiety) on the immediate release so was moved to the extended release. I had talked to my doctor and we are going to use compounding to taper off. I am currently experiencing heart thudding, shaking/quivering, dizziness, cold intolerance, constipation, severe anxiety, and just generally feeling unwell. I am terrified of making the transition to the compounded capsules as my body is sensitive but there’s no way to taper the extended release. So I’m having the pharmacy compound their own slow release version (since I cannot deal with the rebound symptoms from the immediate release). I am also dealing with some vision problems which are taking a while to treat and adding a lot of stress to the situation.

[[Br...]]

Hello @[Ho...] - Welcome to BenzoBuddies!     I'm glad you found a pharmacy to compound a slow release version for you. I hope you feel more stabilized soon.   You may know already but SurvivingAntidepressants.org has a thread on tapering beta blockers including propranolol in their Tapering forum.

[[Ho...]]

5 hours ago, [[B...] said:

Hello @[Ho...] - Welcome to BenzoBuddies!     I'm glad you found a pharmacy to compound a slow release version for you. I hope you feel more stabilized soon.   You may know already but SurvivingAntidepressants.org has a thread on tapering beta blockers including propranolol in their Tapering forum.

Thank you. Yes, I have been splitting my time between both forums. They have some helpful suggestions at surviving antidepressants.

[[Li...]]

 

Hello, @[Ho...].  It’s good to see you back at BenzoBuddies, but I’m so sorry to learn about your issues with vision and propranolol.  Here’s hoping you’ll be able to get both resolved sooner rather than later!

Smart you to check out the resources at Surviving Antidepressants (SA).  I’ve found SA’s ‘tips for tapering’’ docs to be particularly helpful. You’ve obviously already found the one for propranolol that @[Br...] referenced.  But, for the benefit of future readers of this thread, here’s a link to it:

Tips for tapering off propranolol - Tapering - Surviving Antidepressants

 

 

[[Ho...]]

2 minutes ago, [[L...] said:

Hello, @[Ho...].  It’s good to see you back at BenzoBuddies, but I’m so sorry to learn about your issues with vision and propranolol.  Here’s hoping you’ll be able to get both resolved sooner rather than later!

Smart you to check out the resources at Surviving Antidepressants (SA).  I’ve found SA’s ‘tips for tapering’’ docs to be particularly helpful. You’ve obviously already found the one for propranolol that @[Br...] referenced.  But, for the benefit of future readers of this thread, here’s a link to it:

Tips for tapering off propranolol - Tapering - Surviving Antidepressants

Thanks Libertas. Good to see you.

[[Ho...]]

On 18/10/2023 at 14:22, [[L...] said:

Hello, @[Ho...].  It’s good to see you back at BenzoBuddies, but I’m so sorry to learn about your issues with vision and propranolol.  Here’s hoping you’ll be able to get both resolved sooner rather than later!

Smart you to check out the resources at Surviving Antidepressants (SA).  I’ve found SA’s ‘tips for tapering’’ docs to be particularly helpful. You’ve obviously already found the one for propranolol that @[Br...] referenced.  But, for the benefit of future readers of this thread, here’s a link to it:

Tips for tapering off propranolol - Tapering - Surviving Antidepressants

I will say that the tips on surviving Antidepressants don’t really address the issue of Tapering extended release for those of us that are unable to taper the immediate release version. They suggest using a scale to weigh the extended release beads, but everything I’m reading says not to open or crush the capsule etc. I am taking the route of having the immediate release powder compounded with a slow release agent (Methylcellulose) and hoping that’s sufficient to bypass the interdose withdrawal I was experiencing.

[[Li...]]

 

Your concern about changing dosage forms is completely understandable @[Ho...] — there’s no way to know how we will respond until we trial the new form.  Your plan to do so is sound.  In particular, dosing the compounded capsules three times a day makes sense given what the FDA drug labels have to say about the clinical pharmacology of propranolol ER versus regular release propranolol.  (Isn’t it interesting that the ER capsules produce lower blood levels compared to the regular release?)

If getting a second opinion about the formulation your compounder is using would help, you might consider contacting Nick at Pharmacy Solutions in Arlington, TX.  He has helped several of our members with benzodiazepine compounds and I have talked with him myself.  He impressed me as both knowledgeable and patient-centered.

I hope you will let us know how you respond to the compounded capsules and am sending all good thoughts your way for a successful propranolol taper!  

 

[[Ho...]]

1 hour ago, [[L...] said:

Your concern about changing dosage forms is completely understandable @[Ho...] — there’s no way to know how we will respond until we trial the new form.  Your plan to do so is sound.  In particular, dosing the compounded capsules three times a day makes sense given what the FDA drug labels have to say about the clinical pharmacology of propranolol ER versus regular release propranolol.  (Isn’t it interesting that the ER capsules produce lower blood levels compared to the regular release?)

If getting a second opinion about the formulation your compounder is using would help, you might consider contacting Nick at Pharmacy Solutions in Arlington, TX.  He has helped several of our members with benzodiazepine compounds and I have talked with him myself.  He impressed me as both knowledgeable and patient-centered.

I hope you will let us know how you respond to the compounded capsules and am sending all good thoughts your way for a successful propranolol taper!  

Hi Libertas,
 

Thank you for that pharmacy recommendation. My pharmacy is Perrone’s in Fort Worth. I did go to speak with them and it seems they had a solid plan and explanation for what they are doing. I’ve been told, though that I just have to see how the body responds and how long the slow release lasts in my body. I know the extended release I’m taking now lasts exactly 12 hours so I’ve been dosing it twice a day. The slow release mechanisms they are using at the compounders is 24 hours but they can’t exactly promise that. So I’m starting out with three times a day dosing. And will even move it up to four times a day dosing if needed. I’ve been told it’s better to have overlapping half lives anyway, to cover potential interdose withdrawal. It is very interesting about the serum levels between the immediate and extended release. I’ve calculated that my dose of 120 mg extended release is equal to about 60 to 85 mg of immediate release, which sounds better. What I don’t know is the equivalence between the extended release and the compounded, slow release version. They are both touted as 24 hour formulations, but who really knows. I’ll be switching to the same dose and hopes it’s equivalent, but there may be some under or overdosing anyway fingers crossed that it goes well. I will keep you updated.
 

Hope

 

[[Ho...]]

I’m on my second day of the compounded capsules of propranolol with slow release. I am currently taking 40 mg every eight hours. Yesterday was a bit rough but today is even rougher. I am trying to sort out whether I am having a interdose withdrawal or just general withdrawal. I’m going to try to tough it out and see if I stabilize. Otherwise I may need to go to dosing 30 mg every six hours. I’m having a lot of breakthrough symptoms, including heart pounding, shaking, sweaty palms, and mild nausea. I am not tachycardic though. It seems to like each dose works pretty well for the first four hours and then the breakthrough symptoms start for the final four hours, but they aren’t as bad as what I experienced with interdose withdrawal with the immediate release version, so I think the slow release is doing something. Hopefully my body will sort itself out or if I need to change dosing. Hopefully that will alleviate some of this.

[[Ho...]]

I switched to every 6 hour dosing today. 30 Mg to maintain the total daily dose. Symptoms were really ramping up at the 8 hour mark, so hopefully this will cover it. My body is interpreting the lower dose as a cut though. Pretty nasty withdrawal symptoms today, so I’ll hold for a week to stabilize.

[[Fa...]]

Hi, @[Ho...].  I don’t have any experience with propranolol or advise, but I just wanted to stop by and say hello.  I’m sorry you are having a tough time withdrawing from the medication this time around.

I did want to thank you for documenting your ‘journey’ even though you are struggling.  I know it will be helpful for other members, or guests, who may be considering taking, or discontinuing, the medication.

I am about to slowly reduce my baclofen dosage for example and lived  experience, and associated useful content, is scant.  I too was planning to document that ‘journey’.  I wish you the best. 

[[Ho...]]

20 hours ago, [[F...] said:

Hi, @[Ho...].  I don’t have any experience with propranolol or advise, but I just wanted to stop by and say hello.  I’m sorry you are having a tough time withdrawing from the medication this time around.

I did want to thank you for documenting your ‘journey’ even though you are struggling.  I know it will be helpful for other members, or guests, who may be considering taking, or discontinuing, the medication.

I am about to slowly reduce my baclofen dosage for example and lived  experience, and associated useful content, is scant.  I too was planning to document that ‘journey’.  I wish you the best. 

Thanks for dropping by. Good luck on your baclofen taper!

[[Li...]]

Greetings @[Ho...].  Please allow me to join @[Fa...] in thanking you for documenting your propranolol tapering experience.  I’ve no doubt it will help others down the road.

How are you doing with the 6 hour dosing intervals?  Any signs of improvement?  

[[Ho...]]

1 hour ago, [[L...] said:

Greetings @[Ho...].  Please allow me to join @[Fa...] in thanking you for documenting your propranolol tapering experience.  I’ve no doubt it will help others down the road.

How are you doing with the 6 hour dosing intervals?  Any signs of improvement?  

Thanks for asking. It seems that the dosing change put me into withdrawal. The total dose is the same but now each time my body is seeing 10 mg less and I think it’s protesting. So I’m having a lot of breakthrough symptoms during the six hours, especially the latter half of that time period. I also get the impression that the drug release system they use at the compounding pharmacy is somewhat unpredictable. I’m hoping if I hold here for a week that things will stabilize. I plan to start cutting after that.

Edited October 26, 2023 by [Ho...]

[[Li...]]

Well, darn it @[Ho...] this isn’t good news.  Your response to the dosing schedule change reminds me of reports we’ve had from members when they split their benzodiazepine dose(s) to address interdose withdrawal.  Splitting doses works for some individuals, but not for others.  When it doesn’t work — especially when the member is taking a low-ish dose — I often wonder if splitting the dose caused the steady-state serum concentration of the drug to drop below the therapeutic level.

I’m just brainstorming here but if the drug release system being used by the compounding pharmacy turns out to be problematic, might the manufacturer’s oral solution make it easier for you to adjust your dosing amounts and times until you find your ‘sweet spot’? 

DailyMed - PROPRANOLOL HYDROCHLORIDE solution
20 mg per 5 mL oral solution; NDC 0054-3727-63
40 mg per 5 mL oral solution; NDC 0054-3730-63

[[Ho...]]

I know! I think you’re probably right about the serum concentrations. I am feeling a bit better today though. So hopefully I’m on the way to stabilizing. I figure we can consider this my first cut. I’m sick on the drug unfortunately, so probably won’t feel well in the taper anyway. Unfortunately the oral solution is immediate release so I’ll have the same problem with interdose withdrawal that I had with the immediate release tablets. I would probably need to dose it every three hours which isn’t very practical. Otherwise, I would definitely use it. The compounded, slow release, at least provides some coverage of the interdose withdrawal so I’m hoping to get by with it. I don’t really know what else to do.

[[Li...]]

The news that you felt a little better today is encouraging @[Ho...]!  As you know full well, the half-life of propranolol is short so you’ll get feedback on the impact of changes in dose/schedule/form sooner rather than later. 

The manufacturer’s liquid is indeed immediate release.  I just wanted to make sure it was on your radar screen in case you determine something is awry with the slow release component of your compounded capsules.  (Although it’s a long shot, I also wonder if it’s possible your system is ‘unhappy’ that one or more of the excipients in the ER tablets you were taking is now missing?  I recall one member who did not do well on a minimalistic compounded liquid that included only the bulk drug substance, a solvent, and water but was fine when tablets were used as the API source for the liquid). Yes, the daily dosing schedule for the liquid would be a challenge but I’m confident we could devise a way to make it as manageable as possible (e.g. we’ve had members who dosed their liquids 6 times a day and I recall one member who sipped her daily dose throughout the day as needed). 

PS I’m heartened you think my hypothesis about serum concentration may have merit.  I have an opportunity to ask an expert psychopharmacologist about this soon and look forward to what he has to say.

[[Ho...]]

It is good to know there are options. I was also highly symptomatic on the commercial extended release, so I think my body just hates propranolol! Basically an adverse drug reaction but I still have to taper off. Hoping to feel better as the dose decreases.

Edited October 27, 2023 by [Ho...]

[[Ho...]]

I am throwing in the towel and switching to a different beta blocker. I think propranolol is just toxic to my body in any form, but the compounded slow release just didn’t work out. It’s been a roller coaster of symptoms since I started and it’s only getting worse. Symptoms are routinely breaking through a couple hours after t dose. The release mechanism appears to be uneven. I’m switching to Nadolol which is a long acting beta blocker with a 20 to 24 hour half life. It is nonselective for beta receptors just like propranolol. I’m hoping this will cover a lot of my symptoms, although I still expect to experience some withdrawals from propranolol as I titrate off of it. And incidentally, Nick the pharmacist at pharmacy solutions in Arlington gave me the tip about Nadolol. I’ll continue to keep this updated as I’m able.

[[Li...]]

Here’s hoping the nadolol works for you and you start feeling better soon, @[Ho...]. 

You probably already know all this, but just in case not …

If the nadolol does work for you, it looks like you’ll have several options for tapering it when you are ready to do so.  Links to relevant sources below.

(1) Tablets from several of the manufacturers have functional score lines  (e.g. Greenstone). 

(2) I’ve found two stability-tested formulations for 10mg/mL oral suspensions made with regular nadolol tablets (so you’d be able to use the same tablets you’ve been using).

(3) Per USP, nadolol is freely soluble in ethanol and slightly soluble in water, so it may be possible to make an oral nadolol solution.

Another bit of good news … we’d want to verify this, but I found one old source (British National Formulary, 2016) indicating that nadolol is hydrophilic and therefore less likely to cross the blood brain barrier and cause CNS effects.

Links:
DailyMed - NADOLOL tablet (Greenstone)
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0d59bbfc-52a0-4631-9be4-d361a6e61d40&audience=consumer

Nadolol Oral Suspension 10mg/mL - Nationwide Children’s
https://www.nationwidechildrens.org/-/media/nch/specialties/pharmacy/compounding-formulas/nadolol-oral.ashx

Nadolol Oral Suspension 10mg/mL - SickKids
https://www.sickkids.ca/siteassets/care--services/for-health-care-providers/compounding-recipes/nadolol-10mgml-pharmacy-compounding-recipe.pdf

 

[[Ho...]]

1 hour ago, [[L...] said:

Here’s hoping the nadolol works for you and you start feeling better soon, @[Ho...]. 

You probably already know all this, but just in case not …

If the nadolol does work for you, it looks like you’ll have several options for tapering it when you are ready to do so.  Links to relevant sources below.

(1) Tablets from several of the manufacturers have functional score lines  (e.g. Greenstone). 

(2) I’ve found two stability-tested formulations for 10mg/mL oral suspensions made with regular nadolol tablets (so you’d be able to use the same tablets you’ve been using).

(3) Per USP, nadolol is freely soluble in ethanol and slightly soluble in water, so it may be possible to make an oral nadolol solution.

Another bit of good news … we’d want to verify this, but I found one old source (British National Formulary, 2016) indicating that nadolol is hydrophilic and therefore less likely to cross the blood brain barrier and cause CNS effects.

Links:
DailyMed - NADOLOL tablet (Greenstone)
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0d59bbfc-52a0-4631-9be4-d361a6e61d40&audience=consumer

Nadolol Oral Suspension 10mg/mL - Nationwide Children’s
https://www.nationwidechildrens.org/-/media/nch/specialties/pharmacy/compounding-formulas/nadolol-oral.ashx

Nadolol Oral Suspension 10mg/mL - SickKids
https://www.sickkids.ca/siteassets/care--services/for-health-care-providers/compounding-recipes/nadolol-10mgml-pharmacy-compounding-recipe.pdf

Thank you! I was also considering using a scale to file the pills as I’m well versed in that technique.

[[Ho...]]

I was also going to add that Nick kind of discouraged me from using compounded liquid simply because it’s an unknown and not validated etc. At least he was honest! Still always good to have options.