Propranolol

Boxed warning

Propranolol has a boxed warning for adverse effects if the medication is suddenly stopped. Abruptly stopping propranolol treatment can cause potentially fatal myocardial infarction (heart attack).¹

What is propranolol?

Propranolol is a prescription-only drug that belongs to the class of medications known as beta-blockers.²

Propranolol works by relaxing blood vessels, slowing heart rate, and improving blood flow. This makes propranolol an effective treatment for high blood pressure and some other cardiovascular conditions.

What You Need To Know About High Blood Pressure

Warnings and precautions

Do not suddenly stop taking propranolol or stop using the drug without your doctor’s guidance. Suddenly stopping propranolol could worsen your symptoms and even cause a heart attack in some cases.

Propranolol is contraindicated in the following conditions:

• Cardiogenic shock

• Sinus bradycardia and greater than first-degree block

• Bronchial asthma

• Hypersensitivity to propranolol hydrochloride

What is propranolol used to treat?

Doctors prescribe propranolol for:³

• High blood pressure (hypertension)

• Angina caused by atherosclerosis (when the arteries thicken and harden)

• Irregular heart rhythm (atrial fibrillation)

• Heart attack (myocardial infarction)

• Migraine prevention

• Essential tremor

• Pheochromocytoma (a tumor on the adrenal gland)

• Hypertrophic subaortic stenosis (enlarged left ventricle in the heart)

Propranolol ER capsules are only prescribed for:⁴

• High blood pressure

• Angina

• Hypertrophic subaortic stenosis

• Migraine prevention

Hemangeol

In 2014, propranolol was approved as an oral solution to be sold under the brand name Hemangeol. This medicine is prescribed to treat infantile hemangioma (non-cancerous growths or tumors that appear under or on the skin shortly after birth) in children who are five weeks to five months old. Hemangeol should not be given to infants weighing less than 2kg.⁵ ⁶

It is not available as a generic medication.

Dosage forms and strengths

Generic propranolol is available in the following formats:

• Immediate-release oral tablet (10mg, 20mg, 40mg, 60mg, 80mg)³

• Extended-release oral capsule (60mg, 80mg, 120mg, 160mg)⁴

Immediate-release propranolol was previously sold under the brand name Inderal, but this has been discontinued in the US. Now, it is only available as a generic medication.

Extended-release propranolol (propranolol ER) is also available as Inderal LA, Inderal XL, and InnoPran XL. It is released slowly in your body over time, so you only take it once daily.

How do you take propranolol?

Propranolol tablets, capsules, and the solution should be taken by mouth. Swallow the tablets or capsules whole with a glass of water. Do not chew or crush them. The tablet may have a score line allowing you to split it in half for easier swallowing.

Propranolol does not usually upset the stomach. This means you can take it with or without food. However, taking it the same way each day and at the same time is recommended.

Hemangiol should be given to infants either during or just after feeding. Don’t use a regular household spoon to measure a dose; only use the measuring device provided. Do not shake the Hemangeol solution before use.

Dosage

Your exact dose and length of treatment will depend on the nature and severity of your condition. Remember to follow your doctor’s instructions carefully.

Propranolol tablets

Below are the standard immediate-release propranolol doses by health condition.³

• High blood pressure:

  • Initial dose of 40mg twice daily

  • 120–240mg by mouth per day

• Essential tremor:

  • Initial dose of 40mg twice daily

  • Maintenance dose of 120mg by mouth per day

• Pheochromocytoma:

  • 30mg by mouth daily in divided doses (60mg by mouth daily in divided doses for three days before surgery)

• Atrial fibrillation:

  • 10–30mg by mouth three or four times a day before meals and at bedtime

• Myocardial infarction (heart attack):

  • 180–240mg by mouth daily in divided doses

• Angina:

  • Total daily dose of 80–320mg by mouth divided into two, three, or four separate doses

• Migraine prevention:

  • Initial dose of 80mg daily in divided doses

  • The usual effective dose is 120–240mg per day

• Hypertrophic subaortic stenosis:

  • 20–40mg three or four times daily before meals and at bedtime

Propranolol ER capsules

Below are the standard propranolol ER doses by health condition.⁴

• High blood pressure:

  • Initial dose of 80mg once daily

  • Maintenance dose of 120–160mg once daily

• Angina

  • Initial dose of 80mg once daily

  • The average optimal dosage is 160mg once daily

• Hypertrophic subaortic stenosis

  • 80–160mg once daily

• Migraine prevention

  • Initial dose of 80mg once daily

  • The average optimal dosage is 160–240mg once daily

Remember, these are general dosage recommendations. Follow your doctor’s specific advice.

Seeing results

Your body absorbs propranolol a few hours after taking it. The time it takes to obtain the desired effects varies from one person to another. It depends on your dose, the condition being treated and its severity, any other health conditions you have, and any other medications you are taking.

Overall, it may take a few weeks to achieve the desired consistent results from propranolol.

Do not stop taking propranolol without your doctor’s guidance, even if you don’t feel any difference.

Potential side effects of propranolol

Like all medications, propranolol can cause side effects.

Common side effects of propranolol include:³ ⁷

• Bradycardia (slow heart rate) — symptoms may include fatigue, weakness, tiring easily while exercising, shortness of breath, lightheadedness or dizziness, confusion, fainting, or chest pain

• Gastrointestinal issues, like constipation, diarrhea, stomach pain, nausea, or vomiting

• Cold hands and feet (Raynaud’s syndrome)

• Bronchospasms — symptoms may include difficulty breathing, wheezing, coughing, chest tightness, and shortness of breath

• Drowsiness

• Fatigue

• Insomnia

• Vivid dreams

Less common and more serious side effects may include:

• Erectile dysfunction

• Stevens-Johnson Syndrome (a dangerous skin reaction)

• Short-term memory loss

• Drug-induced systemic lupus erythematosus

• Heart failure

Seek medical attention immediately if you develop the following serious side effects:

• Rash

• Hives

• Itchy skin

• Blistering or peeling skin

• Swollen face, throat, tongue, or lips

• Unexplained weight gain

• Trouble breathing or swallowing

• Feeling faint

• Unusual sweating

• Drop in body temperature

• Slow or irregular heartbeat

• Loss of consciousness

Overdose

If you take too much propranolol, you might experience the following effects:⁷

• Slow heart rate

• Low blood pressure

• Feeling dizzy or lightheaded

• Feeling confused

• Tremors

• Rapid, shallow breathing

• Nausea

• Getting tired easily when exercising

• Fainting, or nearly fainting

If you think you or someone else has taken too much propranolol, seek emergency medical help immediately.

Allergy information

Propranolol can cause a severe allergic reaction in rare cases.

Symptoms of an allergic reaction may include:

• Wheezing

• Tightness in your throat or chest

• Difficulty breathing or talking

• Swollen mouth, lips, tongue, throat, or face

• Skin rash

• Fever

• Coughing

• Shortness of breath

If you develop these symptoms after taking propranolol, seek immediate medical help or go to the nearest emergency room.

Long-term use of propranolol

Taking propranolol for a long time is generally thought to be safe. You may need to take this drug long term, since your condition may be lifelong.⁸

Pregnancy category

Propranolol is listed as a pregnancy category C medication. This means animal reproduction studies have shown there could be harmful effects on the fetus, but there are no well-controlled, adequate studies in humans.³

Propranolol and pregnancy

Birth defects and growth retardation in the fetus have been reported in some cases of propranolol use during pregnancy. In cases where the mother took propranolol during labor, slow heart rate in the fetus, hypoglycemia (low blood sugar levels), and/or respiratory issues have been reported.

Therefore, propranolol should only be taken during pregnancy after a thorough evaluation by your doctor, where they have concluded that the benefits of taking the drug justify the potential risk.

Propranolol and breastfeeding

Propranolol passes from the mother to the child through breast milk. Caution is advised while taking propranolol and breastfeeding.

Missed doses

Take a missed dose as soon as you remember. If the time is closer to your next scheduled dose than to your missed one, skip the dose you missed and resume your normal schedule.

Never take two doses of propranolol at once or close in time to each other just to catch up on the dose you missed. Taking double doses can lead to dangerous side effects and increase the risk of overdose.

Speak to your doctor if you regularly forget to take your dose.

Drug interactions

The following drugs can interact with propranolol:³ ²

• Anti-ulcer drugs, such as cimetidine (Tagamet)

• Other beta-blockers, including metoprolol (Lopressor, Toprol XL, or Kapspargo Sprinkle), nebivolol (Bystolic), acebutolol (Sectral), esmolol (Brevibloc), and sotalol (Betapace)

• Calcium channel blockers, including nicardipine (Cardene), diltiazem (Cardizem, Diltzac, and others) and nisoldipine (Sular)

• Anticoagulants (blood-thinners), including warfarin (Jantoven or Coumadin) and heparin

• Non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Motrin, Advil, and others), nabumetone, and naproxen (Aleve, Naprosyn, and others)

• Arrhythmia drugs, including amiodarone (Cordarone or Pacerone), propafenone (Rythmol), quinidine, and digoxin (Lanoxin, Digitek, and others)

• Medications for mental health conditions, including lithium (Lithobid), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Brisdelle, Paxil, or Pexeva), desvenlafaxine (Khedezla, Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor XR), clomipramine (Anafranil), amitriptyline, amoxapine, imipramine (Tofranil), and doxepin

• Migraine medications, including naratriptan (Amerge), almotriptan (Axert), sumatriptan (Imitrex), eletriptan (Relpax), and frovatriptan (Frova)

• Diuretics (water pills)

• Lipid-lowering drugs, such as cholestyramine (Locholest, Prevalite, and Questran) or colestipol (Colestid)

• Ritonavir (Norvir), a protease inhibitor prescribed to treat HIV infection

• Theophylline (Elixophyllin, Quibron-T, and others), prescribed to treat the symptoms of some lung diseases

Chronic Lung Disease: Types, Causes, Symptoms, Prevention, and Treatment

This is not a complete list of potential drug interactions. You must tell your doctor about all medications you take before starting propranolol treatment.

Can I drink alcohol while taking propranolol?

Drinking alcohol during propranolol treatment may increase the concentration of the drug in your body.

What to discuss with your doctor before taking propranolol

Before taking propranolol, tell your doctor if:²

• You are allergic to this drug or others. Tell your doctor if you have had an allergic reaction to propranolol or other beta-blockers in the past.

• You take other medications. Provide your doctor with a list of prescription and non-prescription medications, vitamins, and herbal remedies.

• You have other medical conditions. Tell your doctor your medical history, especially if it involves:

  • Thyroid problems

  • Asthma or any other lung condition

  • Liver disease

  • Kidney disease

  • Cardiovascular disease

  • Pheochromocytoma (tumor of the adrenal gland)

  • Raynaud’s syndrome

  • Diabetes

• You are pregnant, planning a pregnancy, or breastfeeding.

• You use tobacco products (doing so can reduce the effectiveness of propranolol).

Stopping propranolol

If you suddenly stop taking propranolol, you might experience worsening symptoms. This is because your body gets used to beta-blockers over time.⁹

If you take propranolol for hypertension, suddenly stopping the drug might cause your blood pressure to rise. Similarly, it could cause palpitations, a recurrence of angina pain, and even heart attack.

Don’t stop taking propranolol without your doctor’s guidance. They will tell you how to stop taking this drug safely, as propranolol must be discontinued gradually over a period of time.

Drug approval history

1967: The FDA first approved propranolol to be sold as Inderal oral tablets. This branded product has since been discontinued, but generic propranolol IM continues to be available.

1983: Inderal LA (propranolol ER) was approved by the FDA.

2003: InnoPran XL capsules (propranolol ER) were approved by the FDA.¹⁰

Tips and advice for taking propranolol

These tips can help you take propranolol safely and get the best results:

• Take propranolol at the same time daily.

• Take your propranolol dose with or without food.

• Swallow the tablet or capsule whole. Never chew, crush, or break it.

• Limit your alcohol intake while taking propranolol and stay hydrated.

• Avoid activities requiring alertness, like driving or operating heavy machinery, until you know how this medication affects you. Propranolol could cause dizziness.

• Stopping propranolol without medical guidance could be harmful. Keep taking your medication even if you feel better.

Propranolol frequently asked questions

What does propranolol do?

Propranolol is a beta-blocker that helps treat high blood pressure and a number of other cardiovascular conditions by relaxing blood vessels, slowing heart rate, and improving blood flow.

Who should not take propranolol?

Propranolol should not be used in people with cardiogenic shock, sinus bradycardia and greater than first-degree block, bronchial asthma, or hypersensitivity to propranolol hydrochloride.

Propranolol may not be suitable for people taking medications with which it is contraindicated, including other beta-blockers, anti-ulcer drugs, NSAIDs, diuretics, or antiarrhythmic drugs.

Does propranolol relieve anxiety?

Propranolol may be prescribed off-label to ease symptoms of anxiety. However, it is not approved by the FDA for this use.