When should propranolol (beta-blocker) be held?

When to Hold Propranolol

Propranolol should be held in cases of significantly reduced oral intake, vomiting, wheezing requiring treatment, hypotension, bradycardia, and before major surgery in certain patients. 1

Specific Conditions Requiring Propranolol to be Held

Cardiovascular Concerns

• Hold propranolol in patients with sinus bradycardia, hypotension, heart block greater than first-degree, heart failure, or cardiogenic shock 1
• Abrupt discontinuation of propranolol should be avoided in patients with coronary artery disease as it may precipitate exacerbation of angina, and in some cases, myocardial infarction 2
• If propranolol must be discontinued in patients with angina, gradually reduce the dosage over at least a few weeks 2

Respiratory Concerns

• Hold propranolol in patients with active wheezing or bronchospasm requiring treatment 1
• Patients with bronchospastic lung disease (e.g., asthma, COPD) should generally not receive beta-blockers as they may provoke bronchial asthmatic attacks 2

Metabolic Concerns

• Hold propranolol during episodes of hypoglycemia, as beta-blockers may mask certain premonitory signs and symptoms of acute hypoglycemia (pulse rate and pressure changes) 2
• Propranolol should be held at times of diminished oral intake or vomiting to reduce the risk of hypoglycemia, particularly in infants 1

Perioperative Considerations

• While chronically administered beta-blocker therapy should not be routinely withdrawn prior to major surgery, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia 2
• For patients undergoing non-cardiac surgery, beta-blockers should be continued when prescribed for IHD (ischemic heart disease) or arrhythmias 1
• If possible, non-cardiac surgery should be deferred in patients with decompensated heart failure so that it can be performed under optimal medical therapy in a stable condition 1

Special Patient Populations

Infantile Hemangioma Treatment

• For infants receiving propranolol for infantile hemangioma treatment, doses should be held during:
  • Episodes of significantly reduced oral intake 1
  • Vomiting or diarrhea 1
  • Any acute illness interfering with normal oral intake 1

Patients with Comorbidities

• Lower doses may be required for patients with:
  • PHACE syndrome (posterior fossa malformations–haemangiomas–arterial anomalies–cardiac defects–eye abnormalities–sternal cleft and supraumbilical raphe) 1
  • Sleep disturbances 1
  • Progressive infantile hemangioma ulceration while receiving therapy 1

Monitoring After Holding Propranolol

• If propranolol therapy is interrupted and exacerbation of angina occurs, it is usually advisable to reinstitute propranolol therapy along with other measures appropriate for managing unstable angina pectoris 2
• When restarting propranolol after holding it, consider lower starting doses with gradual titration, particularly in high-risk patients 1

Potential Complications of Abrupt Discontinuation

• Abrupt discontinuation may lead to:
  • Exacerbation of angina 2
  • Potential myocardial infarction in patients with coronary artery disease 2
  • Rebound tachycardia 1

Common Pitfalls and Caveats

• Beta-blockers like propranolol may mask the early warning signs of hypoglycemia such as tachycardia and tremor 3
• In patients with diabetes, it may be more difficult to adjust insulin dosage when on propranolol 2
• Propranolol should not be withdrawn in patients treated for stable heart failure due to left ventricular systolic dysfunction 1
• For patients with infantile hemangioma, premature cessation of propranolol may lead to rebound growth of the hemangioma 1