Propranolol

Propranolol was the first Beta Blocker, developed in the 1960s by James Black
1. Dr. Black later won the Nobel Prize in 1988 for Beta Blocker development

Primary
1. Migraine Headache Prophylaxis
2. Esophageal Varices Prevention of Recurrent Bleeding (not FDA approved)
3. Essential Tremor
4. Thyrotoxicosis (Hyperthyroidism) (not FDA approved)
5. Performance Anxiety (not FDA approved)
6. Perioperative Pheochromocytoma Management
  1. Must be used with alpha blocker
Other indications for which Selective Beta Blockers Preferred instead of Propranolol
1. Hypertension
2. Atrial Fibrillation Rate Control

Non-Selective Beta Blocker
Beta 1 Adrenergic Receptor Antagonist
1. Decreases Heart Rate, Cardiac Output, and Sympathetic System output (decreased renin release)
2. Prolongs AV conduction and refractory period
Beta 2 Adrenergic Receptor Antagonist
1. Risk of bronchoconstriction

Patients may have very different responses to various formulations (regular, LA, XL)

Migraine Headache Prophylaxis
1. Regular: Start 40 mg orally twice daily
2. XR/LA: 80 mg orally daily
3. Maximum: 240 mg/day)
Pheochromocytoma Surgery
1. Must be used concurrently with alpha blocker
2. Start three days before surgery: 60 mg orally two to three times daily
Essential Tremor
1. Start 40 mg orally twice daily
2. Target 120 to 320 mg/day
Thyrotoxicosis (not FDA approved)
1. Start 60 to 80 mg orally every 4 hours OR
2. Start 0.5 to 1 mg IV over 10 minutes every 3 hours
Esophageal Varices Prevention of Recurrent Bleeding (not FDA approved)
1. Start 20 to 40 mg orally twice daily
2. Titrate up to 180 mg twice daily as needed, targeting Heart Rate drop of 25% from baseline
Performance Anxiety (not FDA approved)
1. Take 20-40 mg orally as needed 45 minutes before performance

Rarely Used for Hypertension, Angina or SVT management
1. Propranolol has been replaced by newer, selective Beta Blockers for these indications
2. As the first Beta Blocker developed, Propranolol has historical indications for Hypertension, CAD and a fib RVR
Hypertension
1. Propranolol (regular release)
  1. Start 20 to 40 mg orally twice daily
  2. Target 160 to 480 mg/day
  3. Maximum 640 mg/day
2. Propranolol LA (long acting)
  1. Start 60 to 80 mg orally at bedtime
  2. Target 120 to 160 mg daily
  3. Maximum 640 mg/day
Angina
1. Propranolol (regular release)
  1. Start 10 to 20 mg orally three to four times daily
  2. Target 160 to 240 mg/day
  3. Maximum 320 mg/day
2. Propranolol LA (long acting)
  1. Start 80 mg orally at bedtime
  2. Target 160 to 240 mg/day
  3. Maximum 320 mg/day
Atrial Fibrillation Rate Control
1. Start 10 to 30 mg orally three to four times daily
Intravenous Dosing in life threatening Arrhythmia (very rare use)
1. Avoid in Hypertensive Emergency
2. Load: 1-3 mg IV over 2-5 minutes
3. May repeat once in 2 minutes (to a total maximum up to 0.1 mg/kg)
4. Sustained response for 6-8 hours (do not give additional doses for 4 hours)

See Beta Blocker
Transient Hypertension
1. Beta 2 Adrenergic Receptor Antagonists transiently constrict large arteries
Rebound Hypertension
1. Sudden discontinuation of Propranolol
CNS Adverse Effects
1. CNS penetration
Congestive Heart Failure Exacerbation
1. May worsen acute, decompensated CHF

Cimetidine
1. Increases Propanolol serum levels
Alcohol
1. Acute Alcohol Intoxication increases Propranolol levels
2. Chronic Alcohol use decreases Propranolol levels
Digoxin
1. Fatal Third degree AV Block has occurred