Propranolol in Alcohol Use Disorder
Propranolol should NOT be used as first-line therapy for alcohol withdrawal syndrome, as benzodiazepines remain the gold standard treatment with proven efficacy in preventing seizures and delirium tremens—the most critical morbidity and mortality outcomes. 1
Primary Treatment Approach
Benzodiazepines are the only recommended pharmacological treatment for alcohol withdrawal syndrome based on current clinical practice guidelines. 1
- Long-acting benzodiazepines (chlordiazepoxide 25-100 mg every 4-6 hours, or diazepam 5-10 mg every 6-8 hours) are recommended for preventing seizures and reducing mortality risk. 1
- Lorazepam (1-4 mg every 4-8 hours) is preferred for patients with severe AWS, liver failure, advanced age, or respiratory failure. 1
- Thiamine (100-300 mg/day) must be administered to all patients to prevent Wernicke encephalopathy, which directly impacts mortality. 1, 2
Role of Propranolol: Limited and Adjunctive Only
While older research suggests propranolol may reduce some withdrawal symptoms, it has critical limitations that preclude routine use:
What Propranolol Can Do:
- Reduces autonomic hyperactivity symptoms (tachycardia, hypertension, tremor) in mild-to-moderate withdrawal. 3, 4, 5
- May decrease anxiety and normalize hemodynamics in the withdrawal phase. 3, 4
- One study showed atenolol (a related beta-blocker) reduced oxazepam requirements and accelerated normalization of vital signs. 5
Critical Limitations (Why Guidelines Don't Recommend It):
- Propranolol does NOT prevent seizures—the most dangerous complication affecting mortality in alcohol withdrawal. 4
- Propranolol does NOT prevent delirium tremens—another life-threatening complication. 4
- No guideline from major hepatology or addiction medicine societies recommends beta-blockers for AWS. 1, 2
When Propranolol Might Be Considered
Only as adjunctive therapy in highly specific circumstances:
- Refractory supraventricular tachycardia despite adequate benzodiazepine dosing, where immediate cardiovascular stabilization is needed. 6
- Persistent autonomic hyperactivity (severe hypertension, tachycardia) that is not controlled by benzodiazepines alone. 6, 5
- Never as monotherapy—always combined with benzodiazepines to ensure seizure prophylaxis. 4
Common Pitfalls to Avoid
- Do not substitute propranolol for benzodiazepines, as this exposes patients to unacceptable seizure and delirium tremens risk, directly increasing mortality. 1, 4
- Do not use propranolol in patients with contraindications (asthma, severe bradycardia, heart block, decompensated heart failure). 6
- Do not rely on older studies (1970s-1990s) showing propranolol efficacy when current guidelines uniformly recommend benzodiazepines based on superior mortality outcomes. 1
Evidence Quality Assessment
The guideline evidence strongly favors benzodiazepines with A1-level recommendations from multiple societies. 1 The propranolol research consists of small studies from the 1970s-1990s 3, 4, 7, 5 that predate modern understanding of alcohol withdrawal mortality risk and have not been incorporated into any current clinical practice guidelines. 1, 2