Questioning adjusting Propranolol dosage during taper...

[[Fa...]]

Hi All,

I was placed on Propranolol while in the worst of my Akathisia.  I was placed on 20mg twice a day.

As I get lower on Clonazapam, and the Akathisia is not as it once was, I am feeling the effects of the Propranolol a lot more.  Upon taking it, it is now very clear that it is making me dizzy and tired...possibly other smaller things that I have attributed to WD.  I can't keep my eyes open until the dose seems to move away from its peak.

I am so wary of trying to tweak the dose being so symptomatic still.  One drug at at time is how I have wanted to move through this.  I'm just not sure that this is serving me, either.

Having said all of this, I am wondering if I should try to very slowly reduce it.  I know there are contraindications to taking Clonazepam and Propranolol at the same time.  @[Li...] and I have had exchanges in the past regarding this.  Having taken the Propranolol even just 15 minutes apart from the Clonazepam clearly shows that the these symptoms are coming from it, and I can now see how it helped me while in the deep of it all.  Couldn't really see it that clearly before, if at all.

I'm not asking for others' less than positive experiences on it but about potentially trying to lower the dose as I am tapering.  I'm not interested in removing it all together at this time...but, I may be on a dose that is too high for my symptom levels now.  I have a scale...I could go about it very gently.

Thank you.

Warmly 

F

 

 

[[Li...]]

Hello @[Fa...].  First and foremost, tip of the hat for your systematic approach to untangling the effects of clonazepam from those of the propranolol!  I want to review the literature I’ve gathered about propranol before responding but in the interim, would you please remind me how long you’ve been taking it?  It also would be helpful to know (1) your daily dosing times for the propranolol relative to your clonazepam dosing times and (2) the approximate duration of effect of the propranolol.

Lastly, on a scale of 0 to 10, how would you rate the dizziness and tiredness you are experiencing in terms of tolerability and impact on your functionality? (0 = These symptoms are easily tolerated and have no impact on my functionality to 10 = These symptoms are intolerable and have a significant negative impact on my functionality.)

[[Fa...]]

Hi @[Li...],

I've been taking the Propranolol for about 2.5 years.

I never did separate the two drugs' dosing times regardless of what I had learned.  Chalk it up to just doing what I had to at the time.  I have been taking them both at 8 a.m. and 8 p.m.

The last few days, I took the Propranolol first and waited 15-30 minutes before I dosed the Clonazepam in the a.m.  It just happened to work out that way, but I'm glad it did.  There was no system, Libertas.  It was dumb luck.

Within minutes after taking the Propranolol, I was hit with dizziness and tiredness.  This is not new to me and began to sneak up over several months time, but because I was dosing both at same time, and am so used to symptoms being how they are, I didn't have the space to even think to scrutinize what was happening.

After dosing Propranolol, it will peak very shortly after, and it can last for at least a few hours.  It will happen with both doses, a.m. and p.m.

Out of 10, I would rate it about 7-8/10 at peak.  It does not stop me from doing what I need to do, but it is not easy.  But, I would not be able to drive in that condition.  I would consider tweaking things if that seems to be best.  Including, separating the doses.  I am nervous about disrupting things, but I will weigh the options out.

Thank you, as always, for your thoughtful questions and help.  I know I did not make dosing changes a year and a half ago when we had last discussed dosing concerns (very different circumstances at that time).  I remember being very fixated on many other things, and focussed solely on the Clonazepam.  Now, I can look at this from a clearer position/perspective.

BTW.  Blood pressure is normal.  I am not too low.

 

Edited January 10 by [Fa...]

[[Li...]]

Hello again @[Fa...].  Thank you for responding to my questions.  Given your rating of tolerability and impact on functionality, I’d be inclined to  try to improve the situation versus just letting it ride.

The question then becomes, what to try?  One idea would be to try separating the dosing times for the propranolol and the clonazepam with the goal of minimizing the interaction between the two. Another idea would be to try tapering.

I hear you loud and clear being nervous about making any changes!  So when considering options, an important question to ask is which would be the least disruptive? 

If you decide to try a taper …

As I’m sure you already know, propranolol causes physical dependence when taken chronically so a taper is definitely indicated. According to Surviving Antidepressants, “Anti-hypertensives may be tapered somewhat faster than psychiatric drugs. A 10% reduction per week allows blood pressure regulation to adjust.”  However, given your history, I would be inclined to taper much slower than that.

You mentioned you have a scale so you could do a gentle taper.  Are you also aware that propranolol tablets (see Note) are manufactured as hydrochloride salts?  So another option to consider would be to make a do-it-yourself liquid (see link below to a paper on this).  A commercially manufactured oral solution is also available from Hikma; however, the lowest concentration available (20mg/5mL) may be too high for a sufficiently gentle taper. Compounded formulations are also available for both solid and liquid dosage forms.

One final comment about propranolol ….

In reviewing my notes, I re-learned that its bioavailability can be quite variable. For example, per its FDA label, “Administration of protein-rich foods increase the bioavailability of propranolol by about 50% with no change in time to peak concentration, plasma binding, half-life, or the amount of unchanged drug in the urine.”  This is good info to know when thinking about dosing times relative to eating times and types of food consumed.

Note: Just double checking … are your tablets regular — versus extended — release? 

Link:

Giving propranolol tablets to infants with hemangiomas - Solubility in Water - Greenhill et al - 2011 - Journal of Paediatrics and Child Health

 

 

[[Fa...]]

Thanks, @[Li...].  They are regular tablets.

Okay...I'm going to slowly figure out how I will begin to do this...whether water or dry.

When you state slower, do you mean both percentage and time between reductions?  

 

 

[[Li...]]

You’re most welcome @[Fa...].  I’m relieved you are taking regular release tablets — as I’m sure you know, modified release dosage forms are not as ‘taper friendly’ as immediate release forms.

32 minutes ago, [[F...] said:

When you state slower, do you mean both percentage and time between reductions?

I tend to think in terms of taper rate … so a slower taper rate.  Taper rate can be adjusted by changing the amount of the reduction and/or the reduction interval.  Per Mark Horowitz, “Go as fast as you can but as slow as you need to keep symptoms tolerable.”

[[Fa...]]

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

Taper rate can be adjusted by changing the amount of the reduction and/or the reduction interval

Okay...I was focussing on the 10%.

I'm going to just dry cut this time.  It will give me something to do.

Thanks, again, for your help and input.  Will start at 5% and see how it goes from there.

Much Gratitude!

[[Li...]]

Very good, @[Fa...].

I am sending all good thoughts and best wishes your way for a positive outcome!

 

[[Fa...]]

Thank you, @[Li...].  Gonna try to sneak it out.