Rebound withdrawal

A contact dermatitis occurs infrequently. Because feverfew also inhibits human blood platelet aggregation, interactions are possible with antithrombotic medications such as aspirin or warfarin (Groenewegen and Heptinstall 1990). Abrupt discontinuation of feverfew by people taking it chronically for treatment of migraine can produce rebound withdrawal symptoms. These consist of migraines, anxiety, poor sleep patterns, and stiffness of the muscles and joints. 

Type E (end-of-use) reactions occur with rebound withdrawal phenomena. 

Evidence also supports a clinically significant rebound-withdrawal phenomena between doses of alprazolam, sometimes referred to as interdose or breakthrough symptoms (233, 234). Mellor and Jain (218) raised the possibility that some long-term diazepam users may be subject to a similar phenomenon ... 

Physical dependence on benzodiazepines is recognized as a major problem, and occurs after relatively short periods of treatment (50,51), particularly in patients with a history of benzodiazepine or alcohol problems. Abrupt withdrawal can cause severe anxiety, perceptual changes, convulsions, or delirium. It can masquerade as a return of the original symptoms in a more severe form (rebound), or present with additional features (SEDA-17,42 11). Up to 90% of regular benzodiazepine users have adverse symptoms on withdrawal. The differences between rebound, withdrawal syndrome, and recurrence have been reviewed in detail (3). 

Drug discontinuation syndromes, i.e. rebound, withdrawal and resurgence (defined above) are phenomena that are to be expected. In many cases the exact mechanisms remain obscure but clinicians have no reason to be surprised when they occur, and in the case of reboimd they may particularly wish to use gradual withdrawal wherever drugs have been used to modify complex self-adjusting systems, and to suppress (without cure) chronic diseases. 

Clidinium bromide, another quaternary ammonium compound with antimuscarinic activity, is used in a fixed combination with chlordiazepoxide hydrochloride (2.5 mg of clidinium and 5 mg of chlordiazepoxide Librax) however, such combinations are of limited value in patients with IBS because of the risk of habituation and rebound withdrawal. Cimetropium is another antimuscarinic compound that reportedly is effective in patients with IBS. Otilonium bromide has been used extensively for patients with IBS in other parts of the world. It is an ammonium salt with antimuscarinic effects that also appears to block Ca + channels and neurokinin NK-2 receptors. Mebeverine hydrochloride is a derivative of hydroxybenzamide that appears to have a direct effect on the smooth-muscle cell, blocking K+ and Ca channels. It is widely used outside of the United States as an antispasmodic agent for patients with IBS. 

When clonidine is withdrawn abmpdy, patients may experience a rebound hypertensive phenomenon, whereia blood pressure rises rapidly to a level higher than the predmg level. These patients may experience symptoms of headache, tachycardia, agitation, and nervousness. If rebound hypertension occurs, resumption of clonidine therapy or adrninistration of phentolamine reduces the blood pressure. For clonidine withdrawal, the dose should be reduced gradually over a two-week period. The principal side effects are sedation, dry mouth, drowsiaess, di22iQess, and fatigue. 

To prevent a rebound hypoglycemic reaction from the sudden withdrawal of TPN containing a concentrated dose of dextrose, the rate of administration is slowly reduced or the concentration of dextrose gradually decreased. If TPN must be abruptly withdrawn, a solution of 5% or 10% dextrose is begun to gradually reduce the amount of dextrose administered. 

A rebound sleep disturbance has been found after only 7—10 days of treatment with therapeutic doses of triazolam (Greenblatt et al. 1987). Others have described a withdrawal syndrome after substitution of a short-acting benzodiazepine for a long-acting benzodiazepine (Conell and Berhn 1983). Rebound insomnia may occur with zolpidem. 

Greenblatt DJ, Harmatz JS, Zinny MA, et al Effect of gradual withdrawal on the rebound sleep disorder after discontinuation of triazolam. N Engl J Med 317 722-728, 1987... 

On discontinuation of hypnotic BZDRAs, patients can experience rebound effects, specifically rebound insomnia that may last for one to two nights. Rebound insomnia occurs more frequently after discontinuation of shorter-duration BZDRAs compared with long-duration BZDRAs. Intermittent hypnotic therapy with the lowest dose possible reduces the likelihood of tolerance, dependence, and withdrawal when therapy is stopped. Patients should be counseled that rebound insomnia is not necessarily a return of their original symptoms, and it may take a few nights for rebound symptoms to subside. 

Following abrupt withdrawal of anticholinergic medications cholinergic rebound can cause a relapse... 

The recommended dose is prednisone 30 to 60 mg (or an equivalent dose of another corticosteroid) orally once daily for 3 to 5 days. Because rebound attacks may occur upon steroid withdrawal, the dose should be gradually tapered in 5-mg increments over 10 to 14 days and discontinued. 

For treatment of hypertensive rebound after withdrawal of clonidine, 0.2 mg is given initially, followed by 0.2 mg hourly until the DBP falls below 110 mm Hg or a total of 0.7 mg has been administered a single dose may be sufficient. 

Equivalent doses from Chouinard C. Issues in the clinical use of benzodiazepines Potency, withdrawal and rebound. J Qin Psychiatry 2004 65(Suppl 5) 7-12. 

Abrupt withdrawal of TCAs (especially high doses) may result in symptoms of cholinergic rebound (e.g., dizziness, nausea, diarrhea, insomnia,... 

Antipsychotics (especially FGAs and clozapine) should be tapered slowly before discontinuation to avoid rebound cholinergic withdrawal symptoms. 

Likelihood and severity of withdrawal are a function of dose and duration of exposure. Gradual tapering of dosage is necessary to minimize withdrawal and rebound anxiety. 

Once tolerance develops, acute cessation of CNS depressants creates a withdrawal syndrome. Tolerance is associated with neural adaptations to the continued inhibitory influence of the drug. Suddenly removing the drug and its inhibitory influence creates a rebound excitation, due to neuronal disinhibition. Depending on the degree of tolerance, subjects may experience anxiety, irritability, delirium, and seizures. Withdrawal... 

Because GAD is a chronic illness, benzodiazepines are often used in long-term maintenance therapy, leading to physical dependence over the course of several weeks. Consequently, abrupt discontinuation of a benzodiazepine can result not only in rebound anxiety and a rapid relapse but an acute benzodiazepine withdrawal... 

Use of a hypnotic drug should not be extended beyond 4 wk, because tolerance may develop. The risk of a rebound decrease in sleep propensity after drug withdrawal may be avoided by tapering off the dose over 2 to 3 wk. 

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