- Propranolol was the first Beta Blocker, developed in the 1960s by James Black
- Dr. Black later won the Nobel Prize in 1988 for Beta Blocker development
- Primary
- Migraine Headache Prophylaxis
- Esophageal Varices Prevention of Recurrent Bleeding (not FDA approved)
- Essential Tremor
- Thyrotoxicosis (Hyperthyroidism) (not FDA approved)
- Performance Anxiety (not FDA approved)
- Perioperative Pheochromocytoma Management
- Must be used with alpha blocker
- Other indications for which Selective Beta Blockers Preferred instead of Propranolol
- Hypertension
- Atrial Fibrillation Rate Control
- Non-Selective Beta Blocker
-
Beta 1 Adrenergic Receptor
Antagonist
- Decreases Heart Rate, Cardiac Output, and Sympathetic System output (decreased renin release)
- Prolongs AV conduction and refractory period
-
Beta 2 Adrenergic Receptor
Antagonist
- Risk of bronchoconstriction
- Patients may have very different responses to various formulations (regular, LA, XL)
- Dosing
-
Primary Indications
-
Migraine Headache Prophylaxis
- Regular: Start 40 mg orally twice daily
- XR/LA: 80 mg orally daily
- Maximum: 240 mg/day)
-
Pheochromocytoma Surgery
- Must be used concurrently with alpha blocker
- Start three days before surgery: 60 mg orally two to three times daily
-
Essential Tremor
- Start 40 mg orally twice daily
- Target 120 to 320 mg/day
-
Thyrotoxicosis (not FDA approved)
- Start 60 to 80 mg orally every 4 hours OR
- Start 0.5 to 1 mg IV over 10 minutes every 3 hours
-
Esophageal Varices Prevention of Recurrent Bleeding (not FDA approved)
- Start 20 to 40 mg orally twice daily
- Titrate up to 180 mg twice daily as needed, targeting Heart Rate drop of 25% from baseline
-
Performance Anxiety (not FDA approved)
- Take 20-40 mg orally as needed 45 minutes before performance
- Rarely Used for Hypertension, Angina or SVT management
- Propranolol has been replaced by newer, selective Beta Blockers for these indications
- As the first Beta Blocker developed, Propranolol has historical indications for Hypertension, CAD and a fib RVR
-
Hypertension
- Propranolol (regular release)
- Start 20 to 40 mg orally twice daily
- Target 160 to 480 mg/day
- Maximum 640 mg/day
- Propranolol LA (long acting)
- Start 60 to 80 mg orally at bedtime
- Target 120 to 160 mg daily
- Maximum 640 mg/day
-
Angina
- Propranolol (regular release)
- Start 10 to 20 mg orally three to four times daily
- Target 160 to 240 mg/day
- Maximum 320 mg/day
- Propranolol LA (long acting)
- Start 80 mg orally at bedtime
- Target 160 to 240 mg/day
- Maximum 320 mg/day
-
Atrial Fibrillation Rate Control
- Start 10 to 30 mg orally three to four times daily
- Intravenous Dosing in life threatening Arrhythmia (very rare use)
- Avoid in Hypertensive Emergency
- Load: 1-3 mg IV over 2-5 minutes
- May repeat once in 2 minutes (to a total maximum up to 0.1 mg/kg)
- Sustained response for 6-8 hours (do not give additional doses for 4 hours)
- See Beta Blocker
- Transient Hypertension
- Beta 2 Adrenergic ReceptorAntagonists transiently constrict large arteries
- Rebound Hypertension
- Sudden discontinuation of Propranolol
- CNS Adverse Effects
- CNS penetration
-
Congestive Heart Failure Exacerbation
- May worsen acute, decompensated CHF
- Pregnancy Category C
- Consider safe in Lactation
-
Protein bound 90%
- Hepatic metabolism and renal excretion
-
Cimetidine
- Increases Propanolol serum levels
-
Alcohol
- Acute Alcohol Intoxication increases Propranolol levels
- Chronic Alcohol use decreases Propranolol levels
-
Digoxin
- Fatal Third degree AV Block has occurred
- Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 78-9
- Hamilton (2020) Tarascon Pocket Pharmacopoeia
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