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Drug Reference

propranolol

Beta-blocker· Brands: Inderal, Angilol, Deralin, BetachronIVPO

Mechanism of action
Propranolol is a non-selective beta-adrenergic antagonist that competitively blocks beta-1 and beta-2 receptors. This action reduces cardiac output, heart rate, and blood pressure, and decreases renin release from the kidneys. It also has central nervous system effects that contribute to its anxiolytic and migraine prophylactic properties.
Pharmacokinetics
Propranolol is highly lipophilic and well absorbed from the gastrointestinal tract, but undergoes extensive first-pass hepatic metabolism, resulting in an oral bioavailability of approximately 25%. The half-life is typically 3 to 6 hours, though the duration of action may be longer. It is metabolized primarily by CYP2D6 and CYP1A2, and metabolites are excreted in the urine.
Indications & dosing

Hypertension

Start at 40 mg twice daily, adjust according to response.

  • adult · PO: 40–80 mg twice daily · Start at 40 mg twice daily, adjust according to response.

Angina pectoris

Dose is usually 40-80 mg three times daily.

  • adult · PO: 40–80 mg three times daily · Dose is usually 40-80 mg three times daily.

Arrhythmias (including supraventricular tachycardias)

Dose may be increased in severe cases as directed by specialist.

  • adult · PO: 10–40 mg three times daily · Dose may be increased in severe cases as directed by specialist.

Migraine prophylaxis

Start at 40 mg twice daily, increase to 80 mg twice daily if needed.

  • adult · PO: 40–80 mg twice daily · Start at 40 mg twice daily, increase to 80 mg twice daily if needed.

Essential tremor

Start at 40 mg twice daily, titrate to response.

  • adult · PO: 40–80 mg twice daily · Start at 40 mg twice daily, titrate to response.

Anxiety

Start at 40 mg once daily for a week, then increase to 40 mg three times daily if needed.

  • adult · PO: 40 mg three times daily · Start at 40 mg once daily for a week, then increase to 40 mg three times daily if needed.

Thyrotoxicosis

Dose is adjusted to control symptoms such as tachycardia.

  • adult · PO: 20–40 mg three times daily · Dose is adjusted to control symptoms such as tachycardia.

Prevention of variceal bleeding in portal hypertension

Titrate to reduce resting heart rate by about 25% or to 55-60 bpm.

  • adult · PO: 40–80 mg twice daily · Titrate to reduce resting heart rate by about 25% or to 55-60 bpm.
Contraindications & precautions
  • Asthma or history of bronchospasm · Non-selective beta-blockade can precipitate severe bronchospasm.
  • Bradycardia (heart rate <50 bpm) · Risk of further slowing of heart rate and progression to heart block.
  • Second or third degree atrioventricular block · May worsen conduction disturbance and cause complete heart block.
  • Decompensated heart failure · Negative inotropic effect can precipitate further deterioration.
  • Cardiogenic shock · Reduces cardiac output and may be fatal.
  • Sick sinus syndrome · Risk of severe bradycardia and asystole.
  • Untreated phaeochromocytoma · Beta-blockade alone can cause severe hypertension; alpha-blockade must be established first.
  • Severe peripheral arterial disease · May exacerbate intermittent claudication or Raynaud's phenomenon.
  • Do not discontinue abruptly; taper dose over 1–2 weeks to avoid rebound hypertension, tachycardia, or angina.
  • Caution in diabetes: may mask autonomic symptoms of hypoglycaemia such as tremor and palpitations; may also impair glycogenolysis.
  • Caution in thyrotoxicosis: may mask symptoms of hyperthyroidism; abrupt withdrawal can precipitate thyroid storm.
  • Caution in peripheral vascular disease or Raynaud's phenomenon; may worsen symptoms due to vasoconstriction.
  • Caution in history of anaphylaxis: may reduce response to adrenaline; larger doses may be needed.
  • Caution in anaesthesia: may increase risk of profound bradycardia and hypotension; inform anaesthetist.
Adverse effects
  • Bradycardia
  • Fatigue
  • Dizziness
  • Cold extremities
  • Gastrointestinal disturbances
  • Bronchospasmserious
  • Atrioventricular heart blockserious
  • Worsening heart failureserious
  • Masking of hypoglycaemiaserious
Interactions
  • diltiazemmajorAvoid co-prescription where possible, particularly in patients with heart failure, conduction disease or hypotension. If unavoidable, initiate at low doses, monitor heart rate, blood pressure and ECG regularly, and adjust therapy based on findings. Consider using a dihydropyridine calcium channel blocker instead of diltiazem if a calcium antagonist is required.
  • salbutamolmajorAvoid concurrent use of propranolol and salbutamol, especially in patients with asthma or COPD. If an alternative antihypertensive agent is not acceptable, consider a cardioselective beta-blocker (e.g., bisoprolol) at the lowest effective dose. If combined, monitor respiratory function closely, including peak flow or spirometry, and assess symptom control. Advise the patient to report any wheezing, breathlessness, or reduced response to their bronchodilator. Consider increasing the dose of salbutamol or adding an alternative bronchodilator, such as an anticholinergic agent, to maintain airway patency.
  • insulin humanmajorMonitor blood glucose more frequently, especially when starting, stopping, or changing the dose of propranolol. Educate the patient about atypical symptoms of hypoglycaemia, such as sweating or a sense of weakness without tachycardia. Consider using a cardioselective beta-blocker (e.g., atenolol or metoprolol) which may be less likely to mask symptoms, though caution is still advised. Adjust insulin doses as necessary, and advise the patient to carry a source of fast-acting glucose. In high-risk patients, consider advising home glucose monitoring and carrying glucagon.
Renal & hepatic adjustment
  • Hepatic impairment (moderate): Reduce initial dose and titrate cautiously. Monitor for signs of adverse effects.
  • Hepatic impairment (severe): Significant dose reduction required. Consider alternative therapy if possible.
Monitoring, pregnancy & toxicity
  • Heart rate · Regularly, especially during dose titration
  • Blood pressure · Regularly, especially during dose titration
  • Signs of heart failure · Regularly
  • Signs of bronchospasm · Especially in patients with asthma
  • Blood glucose · Regularly in patients with diabetes
  • Symptoms of fatigue or dizziness · Regularly
  • Pregnancy: Use with caution; may be used for hypertension in pregnancy, but monitor for fetal bradycardia, growth restriction, and neonatal hypoglycaemia.
  • Toxicity: Bradycardia · Atropine IV; glucagon for severe bradycardia; cardiac pacing if refractory.
  • Toxicity: Hypotension · IV fluids, glucagon, and vasopressors if needed.
  • Toxicity: Bronchospasm · Inhaled salbutamol (beta2-agonist); consider IV aminophylline if severe.
  • Toxicity: Hypoglycaemia · IV glucose or glucagon.
Antidotes & reversal
  • Glucagon · Bypasses the beta receptor: 1-5 mg IV then infusion; high-dose insulin-euglycaemia for refractory shock.
Clinical notes
Propranolol is indicated for hypertension, angina, arrhythmias, migraine prophylaxis, essential tremor, and anxiety. Caution is advised in patients with asthma or COPD due to beta-2 blockade, in heart failure where it can worsen symptoms, and in diabetics as it may mask hypoglycemia. Abrupt withdrawal should be avoided. Dosage varies widely by indication and should be titrated to effect.

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BNF; local formulary