What are the contraindications for propranolol (beta-blocker)?

Propranolol Contraindications

Propranolol is absolutely contraindicated in cardiogenic shock, sinus bradycardia with greater than first-degree heart block, bronchial asthma, and hypersensitivity to propranolol hydrochloride. 1

Absolute Contraindications

Propranolol should not be used in patients with:

1. Cardiovascular contraindications:

   • Cardiogenic shock 1
   • Sinus bradycardia with greater than first-degree heart block 1
   • Heart failure (decompensated) 2

2. Respiratory contraindications:

   • Bronchial asthma 1
   • Moderate to severe COPD (FEV1 <50% of predicted value) 3
   • Patients on chronic bronchodilator treatment 3
   • Chronic airflow limitation with ≥20% reversibility in airway obstruction 3

3. Other absolute contraindications:

   • Hypersensitivity to propranolol hydrochloride 1
   • Reactive airways 2

Relative Contraindications

These conditions require careful consideration before using propranolol:

1. Cardiovascular:

   • Hypotension 2
   • First-degree heart block (without higher-grade block) 2
   • Compensated heart failure (careful monitoring required) 4
   • Sick sinus syndrome (may worsen bradycardia) 5

2. Metabolic:

   • Hypoglycemia or risk of hypoglycemia 2
   • Diabetes with difficult glycemic control or autonomic neuropathy 3
   • Patients on long-acting oral antidiabetic drugs (risk of prolonged hypoglycemia) 3

3. Vascular:

   • Severe peripheral vascular disease with rest pain 3
   • Vasospastic disorders 3
   • Non-healing vascular lesions 3

Special Considerations

Diabetes

• While not absolutely contraindicated in diabetes, caution is needed in:
  • Patients with signs of autonomic neuropathy
  • Those with difficult glycemic control
  • Patients taking oral long-acting antidiabetic drugs 3

Peripheral Vascular Disease

• Mild to moderate peripheral vascular disease is not a contraindication
• Monitor closely for worsening of claudication symptoms 3
• Avoid in severe disease with rest pain or non-healing lesions 3

Pulmonary Disease

• Safe in mild COPD with FEV1 >50% of predicted value 3
• Contraindicated when history of asthma is present 3

Pediatric Use

• In infants with infantile hemangioma, additional monitoring is required:
  • Hospitalization should be considered for infants ≤8 weeks of age
  • Preterm infants <48 weeks postconceptional age
  • Those with poor social support
  • Those with cardiac or pulmonary risk factors 2

Potential Complications of Propranolol Therapy

Common adverse effects include:

• Sinus bradycardia 2
• Hypotension 2
• Cool extremities 2
• Sleep disturbance 2
• Diarrhea 2
• Hypoglycemia/seizures (particularly in pediatric patients) 2, 6

Risk Mitigation

When using propranolol in patients with relative contraindications:

• Start with lower doses and titrate slowly
• Monitor heart rate and blood pressure closely
• In diabetic patients, monitor blood glucose more frequently
• For patients with mild peripheral vascular disease, monitor for worsening symptoms 3, 6
• In pediatric patients, administer with food and ensure feeding intervals do not exceed 8 hours (or 6 hours in younger infants) to reduce hypoglycemia risk 2