Clonidine Withdrawal

Aka: Clonidine Withdrawal

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II. Risk Factors

  1. Risk increases with total daily doses >0.7 mg/day (esp. >1.2 mg/day, and prolonged use)
  2. Significant withdrawal has occurred at doses of 0.1 mg daily after only 1 week
  3. Concurrent Beta Blocker use
    1. Consider tapering off Beta Blocker several days before stopping Clonidine
    2. Exaggerated hypertensive response related to unopposed Catecholamine-induced Vasoconstriction

III. Findings: Peak 2-4 days after Clonidine cessation

  1. Rebound Hypertension
  2. Diaphoresis
  3. Tachycardia (and Palpitations)
  4. Anxiety
  5. Insomnia
  6. Nausea and Vomiting

IV. Labs

  1. Urine Catecholamine increase (also seen with Pheochromocytoma)
  2. Serum Troponin
  3. Serum Creatinine

V. Diagnostics: Consider based on findings

  1. Head CT
  2. Electrocardiogram

VI. Management

  1. Option 1
    1. Prazosin 10 mg orally twice daily AND
    2. Atenolol 50 mg orally daily AND
    3. Chlordiazepoxide (Librium) 10 mg orally twice daily
  2. Option 2
    1. Propranolol AND
    2. Phentolamine AND
    3. Labetalol
  3. Option 3
    1. Vasodilator (e.g. Hydralazine, Nitroprusside) AND
    2. Beta Blockers

VII. Prevention

  1. Slowly taper dose every 3 to 7 days to prevent rebound Hypertension
  2. Taper Beta Blockers off several days before discontinuing Clonidine
  3. Continue in Clonidine in the perioperative period

VIII. Complications

  1. Myocardial Infarction
  2. Ventricular Tachycardia
  3. Hypertensive Emergency

IX. References

  1. Mishler and Lovecchio (2017) Crit Dec Emerg Med 31(11): 15-20
  2. Bailey (1976) Br Med J 1(6015):942-3 [PubMed]

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