When is propranolol (a beta-blocker) prescribed for adult patients with conditions such as hypertension, angina, arrhythmias, performance anxiety, migraines, or essential tremors?

When Propranolol is Prescribed

Propranolol is prescribed for cardiovascular conditions (hypertension, angina, arrhythmias, post-MI), migraine prophylaxis, essential tremor, performance anxiety, hyperthyroidism, and infantile hemangiomas, with specific indications varying based on its non-selective beta-blocking properties. 1, 2

Cardiovascular Indications

Hypertension

• Propranolol is FDA-approved for hypertension management, though current guidelines do not recommend beta-blockers as first-line agents unless the patient has concomitant ischemic heart disease or heart failure 3, 4
• Typical dosing ranges from 120-160 mg daily, either as divided doses or extended-release formulation 2
• Beta-blockers with higher beta-selectivity (metoprolol, atenolol) are generally preferred over propranolol for uncomplicated hypertension 3

Angina Pectoris and Acute Coronary Syndromes

• Propranolol is indicated for stable angina, with demonstrated efficacy in reducing anginal episodes and prolonging exercise duration 2
• In unstable angina/NSTEMI, propranolol can be administered intravenously (0.5-1.0 mg initial dose, followed by 40-80 mg orally every 6-8 hours) 3
• Avoid in patients with evidence of heart failure, hypotension (SBP <90 mmHg), significant bradycardia (<50 bpm), or high-degree AV block 3

Cardiac Arrhythmias and Hypertrophic Cardiomyopathy

• Propranolol is effective for controlling various cardiac arrhythmias and managing symptoms in hypertrophic subaortic stenosis 2, 5
• In hypertrophic cardiomyopathy, typical dosing is 40-80 mg three times daily, with demonstrated improvement in NYHA functional class 2

Neurological Indications

Migraine Prophylaxis

• Propranolol is FDA-approved and first-line for migraine prevention at doses of 80-240 mg/day 3, 1
• Efficacy is well-established, with propranolol reducing both frequency and severity of migraine attacks 3, 2
• Timolol is the other FDA-approved beta-blocker for this indication, while metoprolol is commonly used off-label 3

Essential Tremor

• Propranolol is first-line treatment for essential tremor, effective in up to 70% of patients 3, 6, 1
• It has been used for this indication for over 40 years with well-documented efficacy 3
• Metoprolol may serve as a second-line alternative, particularly in patients with reactive airway disease, though it is less effective 4

Psychiatric and Performance-Related Indications

Performance Anxiety and Stage Fright

• For situational performance anxiety, propranolol 20-40 mg taken 1 hour before the event is recommended 6, 1
• It works by blocking peripheral effects of adrenaline, reducing rapid heart rate, tremors, and nervousness 6
• This is appropriate for isolated, infrequent events; for chronic performance anxiety, cognitive behavioral therapy or SSRIs/SNRIs are first-line 6, 4

Panic Disorder and PTSD

• In panic disorder, propranolol is commonly prescribed for symptomatic relief of physical symptoms, typically combined with cognitive behavioral therapy and/or SSRIs 3, 6
• When administered immediately after psychic trauma, propranolol may reduce consolidation of emotional memory and serve as prophylaxis for PTSD 3
• Propranolol is not first-line for generalized anxiety disorder or chronic anxiety conditions 6

Endocrine Indications

Hyperthyroidism/Thyrotoxicosis

• Propranolol reduces heart rate and tremor in hyperthyroidism and uniquely inhibits peripheral T4 to T3 conversion 1, 2
• This makes propranolol the preferred beta-blocker for tremor associated with excess thyroid hormone 4
• Abrupt withdrawal may precipitate thyroid storm in hyperthyroid patients 2

Pediatric Indications

Infantile Hemangiomas

• Propranolol is recommended for infantile hemangiomas at a target dose of 3.4 mg/kg/day 1
• Initiation should begin at 1 mg/kg/day with escalation to target dose, with monitoring for hypoglycemia 1
• Most dramatic improvement occurs within 3-4 months of treatment 1

Critical Contraindications

Propranolol is absolutely contraindicated in: 1, 2

• Cardiogenic shock
• Decompensated heart failure with pulmonary edema or rales
• Sinus bradycardia or heart block greater than first degree (without pacemaker)
• Severe hypotension
• Reactive airways disease (asthma, severe COPD)
• Known hypersensitivity to propranolol

Important Safety Considerations

Diabetes and Hypoglycemia

• Beta-blockers may mask early warning signs of hypoglycemia (tachycardia) and increase risk for severe or prolonged hypoglycemia 1, 2
• This is particularly concerning in patients with diabetes, children, fasting patients, or those with renal insufficiency 2

Abrupt Discontinuation

• Never abruptly discontinue propranolol after regular use, as this can cause rebound symptoms, exacerbation of angina, acute myocardial ischemia, or thyroid storm 1, 4, 2
• Gradual tapering is essential when stopping therapy 2

Respiratory Disease

• In patients with mild COPD or history of wheezing, use a cardioselective agent (metoprolol, atenolol) at reduced doses rather than completely avoiding beta-blockade 3
• Propranolol should not be used in patients with asthma or severe bronchospastic disease 3, 2