What are the indications for Propranolol (beta-blocker)?

Propranolol Indications

Propranolol is FDA-approved for hypertension, angina pectoris, migraine prophylaxis, and hypertrophic subaortic stenosis, with extensive evidence supporting its use in essential tremor, performance anxiety, hyperthyroidism, and infantile hemangiomas. 1

FDA-Approved Indications

Cardiovascular Conditions

• Hypertension: Used alone or in combination with thiazide diuretics for blood pressure management (not for hypertensive emergencies) 1
• Angina pectoris due to coronary atherosclerosis: Decreases angina frequency and increases exercise tolerance 1
• Hypertrophic subaortic stenosis: Improves NYHA functional class in symptomatic patients 1

Neurological Conditions

• Migraine prophylaxis: Propranolol 80-240 mg/day has consistent evidence for preventing migraine attacks 2
  • Timolol is also FDA-approved for migraine prevention 2
  • Critical caveat: Propranolol is NOT effective for treating an acute migraine attack once it has started 1
  • Consider propranolol particularly when patients have ≥2 attacks per month producing ≥3 days of disability, or when acute treatments fail 2

Well-Established Off-Label Indications

Pediatric Conditions

• Infantile hemangiomas: FDA-approved formulation (Hemangeol) at 3.4 mg/kg/day shows 60% complete or nearly complete resolution 2
  • Initiate at 1 mg/kg/day and escalate to target dose 2
  • Most dramatic improvement occurs within 3-4 months 2
  • Key precautions: Monitor for hypoglycemia by administering with feeds at ≤8-hour intervals (≤6 hours in younger infants) 2
  • Consider inpatient initiation for infants ≤8 weeks old, preterm infants <48 weeks postconceptional age, or those with cardiac/pulmonary risk factors 2

Movement Disorders

• Essential tremor: First-line treatment with effectiveness in up to 70% of patients 3
  • Propranolol has been used for essential tremor for over 40 years 2
  • Metoprolol may also be effective but is considered second-line 2, 3

Endocrine Conditions

• Hyperthyroidism/thyrotoxicosis: Reduces heart rate and tremor, reverses reduced systemic vascular resistance, and inhibits peripheral T4 to T3 conversion 2
  • Propranolol is the preferred beta-blocker for tremor associated with excess thyroid hormone 3

Psychiatric and Performance Conditions

• Performance anxiety/stage fright: Blocks peripheral effects of adrenaline (rapid heart rate, tremors, nervousness) 3

  • Dose: 20-40 mg taken 1 hour before the performance for situational use 3
  • Can be combined with cognitive behavioral therapy 3
  • Not recommended for generalized anxiety disorder or chronic anxiety 3

• Panic disorder: Commonly prescribed for symptom relief, combined with cognitive behavioral therapy and/or SSRIs and/or benzodiazepines 2

• Post-traumatic stress disorder: May reduce consolidation of emotional memory when administered immediately after psychic trauma 2

Other Conditions

• Portal hypertension: Prophylaxis of upper gastrointestinal bleeding 4
• Pheochromocytoma: Control of symptoms 4, 5
• Cardiac arrhythmias: Management of various rhythm disturbances 4, 5
• Myocardial infarction: Reduction in post-MI mortality 5

Critical Contraindications

Propranolol is absolutely contraindicated in: 2, 3

• Cardiogenic shock
• Sinus bradycardia
• Hypotension
• Heart block greater than first degree (without pacemaker)
• Heart failure (particularly decompensated)
• Reactive airways disease/asthma/COPD
• Known hypersensitivity to propranolol

Important Safety Considerations

Common Side Effects

• Bradycardia, hypotension, fatigue, cold extremities, sleep disturbances (including nightmares occurring in 2-18.5% of patients) 2, 3, 6
• Diarrhea, nausea, dizziness, insomnia 2

Special Precautions

• Diabetes: Use with caution as propranolol may mask hypoglycemia symptoms 2, 3
• Abrupt discontinuation: Never stop suddenly after regular use—can cause rebound symptoms and acute myocardial ischemia 3, 7
• Dental procedures: Limit adrenergic vasoconstrictors and avoid epinephrine-containing gingival retraction cord 7
• Acute illness: Temporarily decrease dosing or cease therapy in children with vomiting, diarrhea, or poor oral intake 2

Dosing Considerations by Indication

• Hypertension/Angina: Average optimum dose 500-800 mg/day for angina (higher than hypertension dosing) 8
• Migraine prophylaxis: 80-240 mg/day 2
• Essential tremor: Variable dosing, titrate to effect 2
• Performance anxiety: 20-40 mg single dose 1 hour before event 3
• Infantile hemangiomas: Target 3.4 mg/kg/day divided doses 2