Rebound effect

This article is about the pharmacological term. For the energy conservation and green marketing term, see Rebound effect (conservation).

Rebound effect or Rebound phenomenon is the tendency of some medications, when discontinued suddenly, to cause a return of the symptoms it relieved -- but the symptoms return stronger than they were before treatment first began. Medications with a known rebound effect can be withdrawn gradually, or, in conjunction with another medication that does not exhibit a rebound effect.

Examples

Sedative hypnotics

Rebound anxiety

Several anxiolytics and hypnotics have a rebound effect: For example, benzodiazepine withdrawal can cause severe anxiety and insomnia worse than the original insomnia or anxiety disorder.^[1] Approximately 70% of patients who discontinue a benzodiazepine experience a rebound effect.^[2] Rebound withdrawal can be a factor in chronic use of medications and drug dependence with patients taking the medications only to ward off withdrawal or rebound withdrawal effects.^[3]

Rebound insomnia

Rebound insomnia is insomnia that occurs following discontinuation of sedative substances taken to relieve primary insomnia. Regular use of these substances can cause a person to become dependent on its effects in order to fall asleep through the process of classical conditioning. Therefore, when a person has stopped taking the medication and is 'rebounding' from its effects, he or she may experience insomnia as a symptom of withdrawal. Occasionally, this insomnia may actually be worse than the insomnia the drug was intended to treat.^[4]

Common medicines known to cause this problem are Eszopiclone and Zolpidem, which are prescribed to people having difficulties falling or staying asleep. This phenomenon can also occur with regular use of anxiolytic drugs, such as benzodiazepines.

Daytime rebound

Rebound phenomena does not necessarily only occur on discontinuation of a prescribed dosage. For example day time rebound effects of anxiety, metallic taste, perceptual disturbances which are typical benzodiazepine withdrawal symptoms can occur the next day after a short acting benzodiazepine hypnotic wears off. Another example is early morning rebound insomnia which may occur when a rapidly eliminated hypnotic wears off which leads to rebounding awakeness forcing the person to become wide awake before he or she has had a full night's sleep. One drug which seems to be commonly associated with these problems is triazolam due to its high potency and ultra short half life but these effects can occur with other short acting hypnotic drugs.^[5][6][7] Quazepam due to its selectivity for type1 benzodiazepine receptors and long half life does not cause day time anxiety rebound effects during treatment, showing that half life is very important for determining whether a night time hypnotic will cause next day rebound withdrawal effects or not.^[8] Day time rebound effects are not necessarily mild but can sometimes produce quite marked psychiatric and psychological disturbances.^[9]

Stimulants

Rebound effects can also occur from stimulants such as methylphenidate or dextroamphetamine. Rebound effects from these medications can include psychosis, depression and a return of ADHD symptoms but in a temporarily exaggerated form.^[10][11][12] Up to a third of ADHD children experience a rebound effect when methylphenidate is withdrawn.^[13]

Antidepressants

Many antidepressants, such as SSRIs, can cause rebound depression or panic attacks and anxiety when discontinued.^[14]

alpha-2 adrenergic agents

Rebound effects can occur after discontinuation of alpha-2 adrenergic agents such as clonidine and guanfacine. The most notable rebound effect of alpha-2 adrenergic agents is rebound hypertension.^[15]

Others

Other rebound effects

An example is the use of highly potent corticosteroids, such as Clobetasol for psoriasis. Abrupt withdrawal can cause a much more severe case of the psoriasis to develop. Therefore, withdrawal should be gradual, diluting the medication with lotion perhaps, until very little actual medication is being applied.

Another example of pharmaceutical rebound is a rebound headache from painkillers when dose is lowered, medication wears off or the drug is abruptly discontinued.^[16]

Continuous usage of topical decongestants (nasal sprays) can lead to constant nasal congestion, known as Rhinitis medicamentosa.

See also

• Physical dependence
• Rebound headache
• Withdrawal syndrome
• Rhinitis medicamentosa

References

1. ^ Kales A, Scharf MB, Kales JD (September 1978). "Rebound insomnia: a new clinical syndrome". Science 201 (4360): 1039–41. doi:10.1126/science.684426. PMID 684426. 
2. ^ Tsutsui S; Zolipidem Study, Group (2001). "A double-blind comparative study of zolpidem versus zopiclone in the treatment of chronic primary insomnia". J. Int. Med. Res. 29 (3): 163–77. PMID 11471853. http://openurl.ingenta.com/content/nlm?genre=article&issn=0300-0605&volume=29&issue=3&spage=163&aulast=Tsutsui. 
3. ^ Hohagen F, Rink K, Käppler C, et al. (1993). "Prevalence and treatment of insomnia in general practice. A longitudinal study". Eur Arch Psychiatry Clin Neurosci 242 (6): 329–36. doi:10.1007/BF02190245. PMID 8323982. 
4. ^ Reber, Arthur S.; Reber, Emily S. (2001). Dictionary of Psychology. Penguin Reference. ISBN 0-140-51451-1. 
5. ^ Kales A, Soldatos CR, Bixler EO, Kales JD (April 1983). "Early morning insomnia with rapidly eliminated benzodiazepines". Science 220 (4592): 95–7. doi:10.1126/science.6131538. PMID 6131538. 
6. ^ Lee A, Lader M (January 1988). "Tolerance and rebound during and after short-term administration of quazepam, triazolam and placebo to healthy human volunteers". Int Clin Psychopharmacol 3 (1): 31–47. doi:10.1097/00004850-198801000-00002. PMID 2895786. 
7. ^ Kales A (1990). "Quazepam: hypnotic efficacy and side effects". Pharmacotherapy 10 (1): 1–10; discussion 10–2. PMID 1969151. 
8. ^ Hilbert JM, Battista D (September 1991). "Quazepam and flurazepam: differential pharmacokinetic and pharmacodynamic characteristics". J Clin Psychiatry 52 Suppl: 21–6. PMID 1680120. 
9. ^ Adam K; Oswald I (May 1989). "Can a rapidly-eliminated hypnotic cause daytime anxiety?". Pharmacopsychiatry 22 (3): 115–9. doi:10.1055/s-2007-1014592. PMID 2748714. 
10. ^ Garland EJ (1998). "Pharmacotherapy of adolescent attention deficit hyperactivity disorder: challenges, choices and caveats". J. Psychopharmacol. (Oxford) 12 (4): 385–95. doi:10.1177/026988119801200410. PMID 10065914. 
11. ^ Rosenfeld AA (February 1979). "Depression and psychotic regression following prolonged methylphenidate use and withdrawal: case report". Am J Psychiatry 136 (2): 226–8. PMID 760559. http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=760559. 
12. ^ Smucker WD, Hedayat M (September 2001). "Evaluation and treatment of ADHD". Am Fam Physician 64 (5): 817–29. PMID 11563573. http://www.aafp.org/afp/20010901/817.html. 
13. ^ Riccio CA, Waldrop JJ, Reynolds CR, Lowe P (2001). "Effects of stimulants on the continuous performance test (CPT): implications for CPT use and interpretation". J Neuropsychiatry Clin Neurosci 13 (3): 326–35. doi:10.1176/appi.neuropsych.13.3.326. PMID 11514638. http://neuro.psychiatryonline.org/cgi/content/full/13/3/326. 
14. ^ Bhanji NH, Chouinard G, Kolivakis T, Margolese HC (2006). "Persistent tardive rebound panic disorder, rebound anxiety and insomnia following paroxetine withdrawal: a review of rebound-withdrawal phenomena". Can J Clin Pharmacol 13 (1): e69–74. PMID 16456219. http://www.cjcp.ca/pdf/CJCP_04-032_e69.pdf. 
15. ^ Vitiello B (April 2008). "Understanding the risk of using medications for attention deficit hyperactivity disorder with respect to physical growth and cardiovascular function". Child Adolesc Psychiatr Clin N Am 17 (2): 459–74, xi. doi:10.1016/j.chc.2007.11.010. PMC 2408826. PMID 18295156. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2408826. 
16. ^ Maizels M (December 2004). "The patient with daily headaches". Am Fam Physician 70 (12): 2299–306. PMID 15617293.