What blood work is needed for someone taking propranolol (beta blocker) and risperidone (atypical antipsychotic)?

Blood Work Monitoring for Propranolol and Risperidone

For patients on risperidone, baseline liver function tests and periodic monitoring during ongoing therapy are prudent, while propranolol requires no routine blood work in most cases.

Risperidone Monitoring Requirements

Baseline Testing (Before Starting)

• Liver function tests (AST, ALT) should be checked before initiating risperidone, as elevations in hepatic transaminase levels can occur, and cases of liver enzyme abnormalities with fatty infiltrates have been reported in adolescent males 1
• Complete blood count (CBC) with differential is recommended at baseline to establish a reference for potential hematological effects 1
• Prolactin level should be measured at baseline given risperidone's strong association with hyperprolactinemia 2
• Fasting glucose and lipid panel are essential baseline measures given metabolic risks 1
• HbA1c should be obtained before starting treatment 1
• Renal function (urea and electrolytes) should be assessed at baseline 1

Ongoing Monitoring During Treatment

• Liver function tests should be monitored periodically during ongoing therapy, as elevations are often transient but can indicate significant hepatic effects 1
• Fasting glucose should be rechecked 4 weeks after initiation, then at 3 months, and annually thereafter 1
• Complete metabolic panel including lipids, HbA1c, and renal function should be repeated at 3 months and annually 1
• CBC monitoring is warranted if any signs of infection develop, as agranulocytosis can occur with any antipsychotic agent, though rare with risperidone 1
• Prolactin levels should be monitored if symptoms of hyperprolactinemia develop (irregular menses, galactorrhea, sexual dysfunction) 2

Critical Hematological Monitoring

If white blood cell count drops to 3,000-3,500/mm³ and absolute neutrophil count remains above 1,500/mm³, monitor CBC with differential biweekly until WBC exceeds 3,500/mm³ 1. If WBC falls below 3,000/mm³ or ANC drops below 1,500/mm³, more intensive monitoring and potential medication discontinuation is required 1.

Propranolol Monitoring Requirements

Baseline Assessment

• No routine blood tests are required before starting propranolol in most patients 1
• Baseline glucose is only needed in selected high-risk cases: preterm infants, low weight patients, those with faltering growth, neonates, or history of hypoglycemia 1
• Renal function should be assessed only if considering adjunctive metformin for metabolic side effects, as metformin should be avoided in renal failure 1

Ongoing Monitoring

• No routine blood work is needed during propranolol treatment 1
• Blood pressure and heart rate monitoring are clinical assessments, not laboratory tests 1

Combined Therapy Considerations

When both medications are used together:

• Follow the more stringent risperidone monitoring protocol for all metabolic and hematological parameters 1
• No additional blood work is required specifically for propranolol beyond what risperidone necessitates 1
• If propranolol is being used adjunctively for akathisia (a risperidone side effect), no additional laboratory monitoring beyond the risperidone protocol is needed 1

Common Pitfalls to Avoid

• Do not order routine CBC, renal, liver, or thyroid profiles for propranolol alone, as these are not indicated and represent unnecessary testing 1
• Do not skip baseline liver function tests for risperidone, as hepatic effects can develop and early detection allows for appropriate management 1
• Do not ignore metabolic monitoring for risperidone, as weight gain and metabolic syndrome are among the most common significant problems with atypical antipsychotics 1
• Do not check glucose only when fasting is impossible - if a random glucose is abnormal, prioritize obtaining a fasting sample 1