Propranolol: Clinical Indications, Dosing, Contraindications, and Adverse Effects
Primary Indications
Propranolol is indicated for cardiovascular conditions (hypertension, angina, arrhythmias, post-myocardial infarction), situational anxiety with prominent somatic symptoms, migraine prophylaxis, essential tremor, hyperthyroidism, and infantile hemangiomas. 1, 2
Cardiovascular Indications
- Hypertension: Propranolol is not recommended as first-line therapy; contemporary guidelines prioritize ACE inhibitors, ARBs, calcium-channel blockers, and thiazide diuretics 1
- Supraventricular tachycardia: Propranolol 30–60 mg daily in divided doses or as single long-acting dose, titrating to 40–160 mg daily 1
- Atrial fibrillation rate control: Immediate-release 10–40 mg three to four times daily 1
- Post-myocardial infarction secondary prevention: Evidence-based indication with proven mortality benefit 1, 2
Anxiety Disorders
- Performance anxiety and situational triggers: Propranolol 10–20 mg taken 30–60 minutes before the anxiety-provoking event (maximum single dose 40 mg) is effective for patients with prominent somatic symptoms (tremor, palpitations, sweating) 1
- Chronic generalized anxiety: Propranolol is explicitly deprecated; SSRIs/SNRIs are first-line 1
Other Indications
- Migraine prophylaxis: Propranolol demonstrates clear short-term superiority over placebo, though long-term efficacy data are lacking 3
- Infantile hemangiomas: Typical dosing 1–3 mg/kg/day, with treatment duration 4–12 weeks followed by gradual taper, completing therapy by 9–12 months of age 4
- Hyperthyroidism: Propranolol provides rapid symptom control; doses should be spaced no more than 8 hours apart 1
Adult Dosing Regimens
Immediate-Release Propranolol
| Indication | Starting Dose | Maintenance Dose | Maximum Dose | Frequency |
|---|---|---|---|---|
| Hypertension | 80 mg/day | 80–160 mg/day | 640 mg/day | Twice daily [1] |
| Supraventricular tachycardia | 30–60 mg/day | 40–160 mg/day | 640 mg/day | Twice daily or single long-acting dose [1] |
| Atrial fibrillation rate control | 10–40 mg | 10–40 mg | — | 3–4 times daily [1] |
| Situational anxiety | 10–20 mg | — | 40 mg single dose | 30–60 minutes before event [1] |
| Ongoing anxiety (not recommended as first-line) | 40 mg twice daily | 80–160 mg/day | — | Twice daily [1] |
Long-Acting Propranolol (LA)
- Hypertension/anxiety: Start 80 mg once daily, titrate to 120–160 mg once daily 1
- Half-life: Immediate-release 3–6 hours; extended-release 8–20 hours 1, 5
Intravenous Propranolol
- Acute settings: 1 mg IV over 1 minute, repeat every 2 minutes as needed, maximum 3 doses (3 mg total) 1
- IV half-life: 2.4 hours 1
Critical Dosing Principles
- Administer with food to reduce hypoglycemia risk, especially in patients with diabetes or diminished oral intake 1
- Hold doses during vomiting or reduced oral intake to prevent hypoglycemia 1
- Never abruptly discontinue: Taper gradually over 1–3 weeks to prevent rebound hypertension, tachycardia, angina, or myocardial infarction 1
Absolute Contraindications
Propranolol must not be initiated in patients with the following conditions:
Cardiac Contraindications
- Second- or third-degree atrioventricular block without a functioning pacemaker 1
- Decompensated heart failure or cardiogenic shock 1
- Severe hypotension (systolic BP <90 mmHg) 1
- Sinus node dysfunction or sinus bradycardia without a pacemaker 1
Respiratory Contraindications
- Asthma or obstructive airway disease: Non-selective β-blockade precipitates life-threatening bronchospasm via β2-receptor antagonism 1
- Even mild wheezing or COPD warrants switching to a cardioselective β1-blocker (metoprolol, atenolol) at reduced doses 1
Metabolic Contraindications
- Recent or ongoing hypoglycemic episodes: Propranolol masks adrenergic warning signs of hypoglycemia (tremor, tachycardia, sweating), leaving only non-adrenergic cues (hunger, confusion) 1
- Diabetic patients require more frequent glucose monitoring 1
Common Adverse Effects
Cardiovascular
- Bradycardia and hypotension: Monitor heart rate and blood pressure, especially at higher doses 1
- Worsening heart failure: Propranolol can reduce cardiac output in susceptible patients 1
Respiratory
- Bronchospasm: Reported in 0.9–12.9% of pediatric patients treated for infantile hemangiomas; may require temporary discontinuation or dose reduction 4
Neuropsychiatric
- Sleep disturbances: Nightmares, night terrors, agitation occur in 2–18.5% of patients; may require earlier-evening dosing or dose reduction 4
- Fatigue, dizziness, cold extremities: Common dose-related effects 1
Metabolic
Neurodevelopmental Concerns
- Theoretical concerns about CNS effects in young children have been raised due to propranolol's lipophilicity and blood-brain barrier penetration 4
- A large prospective randomized trial found no appreciable neurodevelopmental differences at 96 weeks in infants treated for hemangiomas 4
Monitoring Parameters
Pre-Treatment Assessment
- Baseline cardiovascular assessment: Heart rate, blood pressure, auscultation for heart block 1
- Screen for contraindications: Asthma, heart block, decompensated heart failure, hypotension 1
- ECG and echocardiogram: Only needed in selected cases with cardiac concerns; routine blood work (CBC, renal, liver, thyroid function) is not required in otherwise healthy adults 1
Ongoing Monitoring
- Heart rate and blood pressure: Check at each visit during titration 1
- Signs of excessive β-blockade: Dizziness, marked fatigue, heart rate <50 bpm, systolic BP <90 mmHg, new or worsening dyspnea/wheezing 1
- Hypoglycemia vigilance: Especially in diabetic patients; monitor blood glucose more frequently 1
Special Populations
- Infants ≤8 weeks or preterm <48 weeks postconceptional age: Consider inpatient hospitalization for initiation 1
- Elderly patients: May require lower doses due to altered pharmacokinetics 1
Drug Interactions
Major Interactions
- Non-dihydropyridine calcium-channel blockers (diltiazem, verapamil): Avoid routine combination due to markedly increased risk of bradycardia and heart block 1
- Dofetilide: Contraindicated when used with propranolol 1
- CYP2D6, CYP1A2, CYP2C19 inhibitors: May elevate propranolol concentrations 1
Dental Considerations
- Adrenergic vasoconstrictors: Limit dosage and avoid gingival retraction cord containing epinephrine; propranolol can cause hypertensive responses to exogenous epinephrine via unopposed α-adrenergic stimulation 6
- Monitor blood pressure 5 minutes after local anesthesia to detect systemic response 6
Alternative Therapies
When Propranolol Is Contraindicated or Unsuitable
| Clinical Situation | Recommended Alternative | Typical Dosing |
|---|---|---|
| Renal dysfunction | Metoprolol tartrate (cardioselective, no renal adjustment) | 25 mg twice daily; max 200 mg twice daily [1] |
| Once-daily dosing with renal impairment | Atenolol (requires renal dose adjustment) | 25–50 mg once daily; max 100 mg once daily [1] |
| Reactive airway disease | Metoprolol (cardioselective) with extreme caution, or diltiazem/verapamil for rate control (not effective for tremor/anxiety) | Metoprolol 25 mg twice daily [1] |
| Chronic anxiety | SSRIs (escitalopram, sertraline) or SNRIs (venlafaxine) | Per standard psychiatric dosing [1] |
| Migraine prophylaxis | Calcium antagonists, other beta-blockers | Comparable efficacy to propranolol [3] |
Cardioselective β-Blockers
- Metoprolol and atenolol are relatively selective for β1-receptors, reducing (but not eliminating) bronchospasm risk 1
- All β-blockers retain some risk of bronchospasm at therapeutic doses; extreme caution is required in any history of reactive airway disease 1
Critical Safety Warnings
Abrupt Discontinuation
Never abruptly discontinue propranolol after chronic use. Sudden withdrawal can precipitate:
- Severe exacerbation of angina 1
- Myocardial infarction 1
- Ventricular arrhythmias 1
- Rebound hypertension and tachycardia 1
- Taper gradually over 1–3 weeks when discontinuation is necessary 1
Hypoglycemia Masking
- Propranolol masks typical adrenergic warning signs of hypoglycemia (tremor, rapid heartbeat, sweating) 1
- Patients—especially those with diabetes—must rely on non-adrenergic cues (hunger, confusion, sweating) and monitor blood glucose more frequently 1
Cardiogenic Shock Risk
- Propranolol is absolutely contraindicated in cardiogenic shock 1
- Screen for signs of low cardiac output before any dose is given 1
Common Pitfalls
- Using propranolol for chronic generalized anxiety: SSRIs/SNRIs are first-line; propranolol is only appropriate for situational anxiety with somatic symptoms 1
- Failing to taper when discontinuing: Abrupt cessation increases mortality risk 2.7-fold 1
- Ignoring respiratory contraindications: Even mild asthma is an absolute contraindication; switch to cardioselective β-blockers if β-blockade is essential 1
- Combining with non-dihydropyridine calcium-channel blockers: Routine combination with diltiazem or verapamil markedly increases bradycardia and heart block risk 1
- Inadequate hypoglycemia monitoring in diabetics: Propranolol blunts adrenergic symptoms, delaying recognition of low blood glucose 1