How does propranolol (beta blocker) affect sleep?

Propranolol's Impact on Sleep

Propranolol commonly causes sleep disturbances including nightmares, night terrors, and increased nighttime awakenings due to its lipophilic properties that allow it to cross the blood-brain barrier and affect central nervous system function. 1

Mechanisms of Sleep Disruption

• Propranolol crosses the blood-brain barrier due to its lipophilic properties, contributing to central nervous system effects including sleep disturbances 2
• The drug decreases nocturnal melatonin production by approximately 80% through specific inhibition of adrenergic β1-receptors, which may contribute to sleep disruption 3
• Sleep disturbances occur in approximately 2-18.5% of patients treated with propranolol 1

Types of Sleep Disturbances

• Common sleep issues include:

  • Sleep disturbances and sleeping disorders 1
  • Agitation during the night 1
  • Nightmares or night terrors 1
  • Increased nighttime awakenings 4
  • Reduced REM sleep 4

• In controlled trials, lipophilic beta-blockers like propranolol increased:

  • Subjective reports of nighttime awakening 4
  • Recollection of dreaming (paradoxically, despite actual reduction in REM sleep) 4

Clinical Considerations

• Treatment modifications that may help manage sleep disturbances include:

  • Reduction in dosage 1
  • Earlier-evening dosing to minimize nighttime effects 1
  • In severe cases, early discontinuation of therapy may be necessary 1

• Weight gain associated with propranolol may potentially exacerbate obstructive sleep apnea, although direct studies on propranolol's effect on OSA are lacking 1

Special Populations

• In pediatric patients treated for infantile hemangiomas:
  • Sleep disturbances are recognized as a potential adverse effect requiring monitoring 1
  • Clinicians should educate caregivers about this potential side effect 1
  • However, a recent prospective study of infants and toddlers (80% under 6 months) found that propranolol did not significantly impair sleep quality, with most parents considering the impact on sleep to be only a minor problem 5

Monitoring and Management

• Evaluate patients for sleep disturbances when initiating propranolol therapy 1
• Consider that propranolol-induced lethargy may be mistaken for worsening of underlying conditions 2
• In cases of significant sleep disruption, consider:
  • Dose reduction if therapeutic effect can be maintained 2
  • Switching to a less lipophilic beta-blocker with reduced blood-brain barrier penetration 2
  • Administering the medication earlier in the day to minimize nighttime effects 1

Comparative Effects Among Beta-Blockers

• Lipophilic beta-blockers (propranolol, metoprolol, pindolol) have greater effects on sleep than hydrophilic ones like atenolol 4
• The specifically beta-blocking (S)-enantiomers of propranolol and atenolol decrease nocturnal melatonin production, while non-beta-blocking (R)-enantiomers have no effect 3
• Carvedilol, which blocks both alpha and beta receptors, does not appear to decrease melatonin production 3