What is propranolol used for?

What is Propranolol Used For?

Propranolol is a nonselective beta-adrenergic receptor blocker used primarily for cardiovascular conditions (hypertension, angina, arrhythmias, myocardial infarction), infantile hemangiomas, migraine prophylaxis, essential tremor, anxiety with prominent physical symptoms, hyperthyroidism, and portal hypertension. 1

Primary Cardiovascular Indications

Propranolol's cardiovascular applications stem from its ability to block beta-adrenergic receptors, reducing heart rate, cardiac output, and blood pressure 1:

• Hypertension: Reduces blood pressure through decreased cardiac output, inhibition of renin release, and diminished sympathetic outflow from the brain 1
• Angina pectoris: Decreases myocardial oxygen demand by blocking catecholamine-induced increases in heart rate, blood pressure, and myocardial contractility 1, 2
• Cardiac arrhythmias: Exerts antiarrhythmic effects through beta-blockade and quinidine-like membrane stabilization 1, 2
• Post-myocardial infarction: Reduces mortality when used after heart attack 3
• Hypertrophic cardiomyopathy: Controls symptoms related to excessive cardiac contractility 2

Infantile Hemangiomas (First-Line Treatment)

Propranolol is the first-line treatment for proliferating infantile hemangiomas requiring intervention, with an 86-91% response rate. 4

Specific Indications for Treatment 4:

• Ulcerated hemangiomas: Particularly those causing pain or bleeding
• Functional impairment:
  • Vision-threatening periocular lesions (can cause amblyopia in up to 80% if untreated) 4
  • Airway obstruction (especially with "beard distribution" lesions) 4
  • Feeding difficulties from lip or nasal lesions 4
• Risk of disfigurement: Central face, nose, lips, and ear lesions that distort anatomical landmarks 4

Dosing for Infantile Hemangiomas 4:

• Standard starting dose: 1 mg/kg/day divided into three doses, increased to 2 mg/kg/day after 24 hours
• High-risk patients (preterm, comorbidities): Start at 0.5 mg/kg/day with inpatient monitoring
• Treatment duration: Most cases can stop at 12 months of age; majority don't need treatment beyond 17 months 4
• Response timeline: Color lightening and softening typically occurs within hours to days 4

Neurological and Psychiatric Conditions

• Migraine prophylaxis: Mechanism unclear but likely involves beta-receptor blockade in pial brain vessels 1, 2, 3
• Essential tremor: Controls tremor through peripheral beta-blockade 2, 3
• Performance anxiety: Most effective for physical/somatic symptoms (tremor, palpitations, tachycardia, sweating) rather than cognitive anxiety 5, 6
  • Typical dose: 10-40 mg taken 30-60 minutes before performance 6
  • Not recommended for chronic generalized anxiety disorder 5

Other Established Uses

• Hyperthyroidism: Controls sympathetic overactivity symptoms (tachycardia, tremor) 2, 7
• Pheochromocytoma: Manages catecholamine excess (only after alpha-blockade established) 8, 2
• Portal hypertension: Prevents upper gastrointestinal bleeding in cirrhotic patients 2, 3

Critical Contraindications (Absolute)

Never use propranolol in patients with: 5, 6

• Second or third-degree heart block
• Decompensated heart failure or cardiogenic shock
• Asthma or severe reactive airway disease
• Sinus bradycardia (HR below normal for age)
• Active bronchospasm

Essential Pre-Treatment Assessment

Before initiating propranolol, perform 4, 6:

• Cardiovascular examination: Auscultation for murmurs, peripheral pulse palpation, heart rate and blood pressure measurement
• ECG indicated if: Abnormal heart rate for age, family history of sudden death/arrhythmia, syncope episodes, maternal connective tissue disease 4
• Echocardiogram required for: Segmental infantile hemangiomas, heart murmurs, abnormal heart rate 4
• Screening for: Bronchospasm history, diabetes (propranolol masks hypoglycemia), concurrent cardiac medications 5, 6

Common Pitfalls and Safety Warnings

• Never abruptly discontinue: Can precipitate rebound hypertension, tachycardia, or angina—always taper gradually 5, 6
• Hypoglycemia masking: Propranolol blocks adrenergic symptoms of low blood sugar in diabetics; counsel patients accordingly 6, 9
• Feeding requirement for infants: Must maintain regular feeds to prevent hypoglycemia; stop propranolol if oral intake decreases 4
• Drug interactions: Avoid combining with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe bradycardia risk 5
• Sleep disturbances: Occur in 2-18.5% of patients, including nightmares and night terrors 9