Is Propranolol Safe with Vardenafil?
Yes, propranolol is safe to use with vardenafil—there is no contraindication to combining beta-blockers with PDE5 inhibitors, and this combination is commonly used in clinical practice without significant adverse effects. 1, 2
Key Safety Evidence
The combination of beta-blockers (including propranolol) with PDE5 inhibitors like vardenafil produces only small, clinically insignificant additive decreases in blood pressure that do not result in increased adverse events. 2, 3
Beta-blockers are explicitly considered safe during pregnancy in patients with hypertrophic cardiomyopathy, including propranolol, metoprolol, bisoprolol, labetalol, and pindolol, demonstrating their broad safety profile even in vulnerable populations. 1
The Princeton III Consensus specifically notes that beta-blockers like nebivolol (which has vasodilating properties) are less likely to cause erectile dysfunction than other beta-blockers, and the guidelines encourage consideration of cardiovascular medication effects on erectile function rather than contraindicating PDE5 inhibitors. 1
Hemodynamic Effects
When PDE5 inhibitors are administered to patients taking antihypertensive agents including beta-blockers, the blood pressure changes are minimal and well-tolerated:
In patients taking antihypertensive medications (including beta-blockers), sildenafil produced treatment-related adverse events in 34% versus 38% in those not taking antihypertensives, showing no increased risk. 3
The incidence of hypotension, dizziness, and syncope was similar between patients taking and not taking antihypertensive medications with PDE5 inhibitors. 3
Multiple antihypertensive medications from different classes had no effect on the adverse event profile of PDE5 inhibitors. 3
Critical Distinction: The Nitrate Contraindication
The absolute contraindication is between nitrates and PDE5 inhibitors—not beta-blockers and PDE5 inhibitors:
After vardenafil use, wait at least 24 hours before administering any nitrate therapy (compared to 48 hours for tadalafil). 1, 4
The combination of PDE5 inhibitors with nitrates causes profound hypotension, myocardial infarction, and potentially death—this is a Class III (harm) recommendation. 1, 4
Beta-blockers are recommended as first-line anti-ischemic therapy when nitrates are contraindicated due to recent PDE5 inhibitor use. 4
Clinical Approach
When prescribing vardenafil to a patient on propranolol:
Monitor for additive mild blood pressure lowering effects, though these are typically asymptomatic. 2
Always verify the patient is not taking nitrates before prescribing vardenafil, as this is the true contraindication. 4
Document which PDE5 inhibitor and when it was last taken for emergency situations where nitrates might be needed. 4
Common Pitfall to Avoid
Do not confuse the alpha-blocker interaction with the beta-blocker profile. Some patients develop orthostatic hypotension when PDE5 inhibitors are combined with alpha-blockers (like tamsulosin for benign prostatic hypertrophy), requiring precautions. 2, 5 This is distinct from beta-blockers, which have a favorable interaction profile with vardenafil. 2, 3