Propranolol

Propranolol belongs to a group of medicines called beta blockers. Propranolol is used for High blood pressure (hypertension), Angina (chest pain due to coronary atherosclerosis) and Migraine prevention.

Also called: Hemangeol (United States) · Half Inderal (United Kingdom) · Hemangiol (Canada)

Pronunciation: pronunciation varies by local usage.

Generic name: propranolol hydrochloride
Brand names: Bedranol, Beta-Prograne, Half Beta-Prograne
Drug class: Non-selective beta-adrenergic blocker
Form: Tablets, slow-release capsules, or liquid that you swallow (UK source). US tablet prescribing information is the basis of the US dose details in this draft.
Route: By mouth
Legal status: Prescription-only medicine (UK source: only available on prescription)

Availability and supply rules vary by country

Trade names by country: United States · United Kingdom · Canada

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What propranolol hydrochloride is and how it works

Propranolol belongs to a group of medicines called beta blockers. It slows down the heart rate and makes it easier for the heart to pump blood around the body. It is used to treat heart problems, help with some of the symptoms of anxiety, and prevent migraines. (2) (3) (4)

Propranolol is only available on prescription. It usually starts to work in a few hours. For heart conditions or high blood pressure it can take 2 to 3 weeks to work fully, and for migraines it can take several weeks to make a real difference. Treatment aims and duration differ by reason for use. US and UK labelling differs; where this draft states a country, that wording applies to that country.

Mechanism of action: how propranolol hydrochloride works

Propranolol is a non-selective competitive beta-adrenergic receptor blocker with no other autonomic activity. The antihypertensive mechanism is not fully established; contributors include decreased cardiac output. It slows the heart rate and makes it easier for the heart to pump blood around the body. For anxiety it blocks the effects of adrenaline and noradrenaline, reducing the physical signs of anxiety. It is not fully understood how it prevents migraines; it may work by relaxing the blood vessels involved, or by reducing activity in the visual cortex. (2) (4)

What is Propranolol hydrochloride used for?

High blood pressure (hypertension)

US labelling lists hypertension, but states propranolol is not for hypertensive emergencies. UK information lists treating high blood pressure and helping prevent future heart disease, heart attacks and strokes. (2) (4)

Angina (chest pain due to coronary atherosclerosis)

US labelling lists angina pectoris due to coronary atherosclerosis. UK information lists helping prevent chest pain caused by angina. (2) (4)

Irregular heartbeat (arrhythmia), including atrial fibrillation

US labelling lists rate control in atrial fibrillation with rapid ventricular response. UK information lists treating conditions that cause an irregular heartbeat (arrhythmia), like atrial fibrillation. (2) (4)

After a heart attack (myocardial infarction)

US labelling lists reducing cardiovascular mortality in clinically stable survivors of the acute phase of myocardial infarction. (2)

Migraine prevention

US labelling lists prophylaxis of common migraine, but not for treating an attack already started. UK information lists preventing migraines. (2) (4)

Essential tremor

US labelling lists familial or hereditary essential tremor; it reduces amplitude, not frequency, and is not for parkinsonian tremor. (2)

Hypertrophic subaortic stenosis

US labelling lists hypertrophic subaortic stenosis. (2)

Pheochromocytoma

US labelling lists use as an adjunct to alpha-blockade in pheochromocytoma. (2)

Too much thyroid hormone (thyrotoxicosis)

UK information states propranolol can help reduce symptoms if there is too much thyroid hormone in the body; it is usually taken together with medicines to treat an overactive thyroid. (4)

Anxiety (outside FDA-approved indications)

Propranolol is also sometimes used to treat anxiety; this is outside the FDA-approved indications. Propranolol treats the physical symptoms of anxiety, for example stopping the heart beating too fast, and is usually only taken for a short time. No dose is given on this page for this use. (3) (4)

Before taking propranolol hydrochloride

Do not take / not appropriate for

US labelling lists contraindications including cardiogenic shock, sinus bradycardia and greater than first-degree heart block, bronchial asthma, and known hypersensitivity to propranolol. Suitability is a decision for the prescriber under the exact local label. (all products) (2)

Tell your clinician about

UK information asks you to tell your doctor before starting if you have ever had an allergic reaction to propranolol or any other medicine.
If you have low blood pressure, a slow heart rate, or heart failure which is getting worse.
If you have ever had depression or had thoughts about harming yourself.
If you have diabetes, or liver or kidney problems.
If you have severe blood circulation problems in your limbs (such as Raynaud's), which may make your fingers and toes tingle or turn paler than usual or blue.
If you have metabolic acidosis, lung disease or asthma.
If you have a rare tumour of the adrenal glands (phaeochromocytoma).
If you are pregnant, trying to get pregnant, or breastfeeding.
US labelling notes propranolol may mask premonitory signs of acute hypoglycemia, especially in labile insulin-dependent diabetes, and may mask the signs of hyperthyroidism.
US labelling notes patients with bronchospastic lung disease should generally not receive beta-blockers.

(2) (4)

Propranolol hydrochloride dosage and how to take it

Your first dose may make you feel dizzy, so take it at bedtime. After that, if you do not feel dizzy, you can take it in the morning. Do not drive, cycle or operate tools or machinery if you feel dizzy.
Swallow tablets whole with a drink of water. Some brands have a score line to help you break the tablet in half; check the information leaflet for your brand to see if you can do this.
If you take slow-release capsules, swallow them whole with a drink of water and do not break, chew or crush them.
If you take propranolol as a liquid, use the plastic syringe or spoon supplied to measure the dose. If you do not have one, ask your pharmacist. Do not use a kitchen teaspoon.
Propranolol does not usually upset the stomach, so you can take it with or without food; it is best to do the same each day.
Always follow the instructions from a pharmacist or doctor, or the leaflet in the medicine packet.
US labelling states the dose must be individualised because bioavailability varies.

(2) (4)

Procedures and treatment changes

Tell the treating team before surgery, procedures, or any medicine change. Do not alter treatment without the responsible clinician. (2) (3) (4)

Missed dose

If you forget to take a dose, take it as soon as you remember, unless it is nearly time for your next dose; in this case leave out the missed dose and take your next dose at the usual time. Never take 2 doses at the same time and never take an extra dose to make up for a forgotten one. If you often forget doses, an alarm or advice from your pharmacist may help.

Overdose

An overdose of propranolol can be very serious. It can significantly slow the heart rate, lower blood pressure, cause dizziness, seizures or fits, and make it difficult to breathe. The amount that can lead to an overdose varies from person to person. UK advice: call 999 or go to A&E if you take more than your prescribed dose and you have a slow heart rate, breathing problems, feel dizzy or shaky, have a seizure or fit, or have chest pain or a fast heart rate; contact 111 for advice now if you have taken more than your prescribed dose. Do not drive yourself to A&E. Bring the propranolol packet or leaflet, plus any remaining medicine and any other medicine you take. US labelling describes hypotension and bradycardia in overdose; hospital treatment may include glucagon, atropine, other drugs or temporary pacing, and propranolol is not significantly dialysable. Call emergency services or poison control immediately. (2) (4)

Propranolol hydrochloride side effects

Like all medicines, propranolol can cause side effects in some people, but many people have no side effects or only minor ones. Side effects often improve as the body gets used to the medicine.

Feeling dizzy, tired or weak

What to notice: Common (more than 1 in 100 people); usually mild and do not last long. Dizziness is more likely when starting or after a bigger dose.

What to do: As the body gets used to propranolol these should wear off. If you feel dizzy, sit or lie down until you feel better. It is best not to drink alcohol as it will make you feel worse. Do not drive or ride a bike until you feel better. (4)

Cold fingers or toes

What to notice: Common; usually mild and does not last long.

What to do: Put your hands or feet under warm running water, massage them and wiggle your fingers and toes. Do not smoke or have caffeine drinks, as this can narrow blood vessels further. Try mittens and warm socks and do not wear tight watches or bracelets. (4)

Headaches

What to notice: Common; usually mild and does not last long.

What to do: Rest and drink plenty of fluids; it is best not to drink too much alcohol. Ask your pharmacist to recommend a painkiller. Talk to your doctor if they do not go away or are severe. (4)

Feeling or being sick

What to notice: Common; usually mild and does not last long.

What to do: Stick to simple meals and do not eat rich or spicy food. If being sick, try small frequent sips of water to avoid dehydration. If you take the combined pill or progestogen-only pill and you are being sick, your contraception may not protect you from pregnancy; check the pill packet for advice. (4)

Diarrhoea

What to notice: Common; usually mild and does not last long.

What to do: Drink lots of fluids to avoid dehydration. Do not take other medicines to treat diarrhoea without speaking to a pharmacist or doctor. If you take the combined pill or progestogen-only pill and have severe, watery diarrhoea or diarrhoea lasting more than 24 hours, your contraception may not protect you from pregnancy; check the pill packet for advice. (4)

Difficulty sleeping or nightmares

What to notice: Common; usually mild and does not last long. US labelling notes fatigue, lethargy and vivid dreams are dose-related for immediate-release forms.

What to do: Avoid a big meal, smoking, or drinking alcohol, tea or coffee in the evening. Try not to watch television or use a mobile phone before going to bed; relax for an hour before bedtime. Talk to a doctor or pharmacist if this does not help and the side effect still bothers you. (2) (4)

Other reactions reported in US labelling

What to notice: Bradycardia, congestive heart failure, AV block intensification, hypotension, Raynaud-type arterial insufficiency; light-headedness, depression with insomnia, lassitude, weakness, fatigue, visual disturbances, hallucinations, vivid dreams; nausea, vomiting, abdominal cramping, diarrhea, constipation; hypersensitivity reactions including agranulocytosis.

What to do: Discuss persistent or troublesome symptoms with the prescribing team rather than changing treatment yourself. (2)

Possible low platelet count (thrombocytopenia)

What to notice: Bruising, or bruising more easily than usual.

What to do: Contact a doctor or call 111 straight away. (4)

Possible heart problems

What to notice: Shortness of breath with a cough that gets worse when you exercise (like walking up stairs), swollen ankles or legs, or an irregular heartbeat.

What to do: Contact a doctor or call 111 straight away. (4)

Weight changes, sexual problems, or other concerns

What to notice: Some people report putting on weight, especially in the first few months; some report lower sex drive or, in men, being unable to get an erection. These are not known to be common and there is not enough information to say for sure that propranolol causes them.

What to do: Speak to your doctor if you are worried. (4)

Serious warnings

Anaphylaxis (serious allergic reaction) — emergency

Symptoms: Lips, mouth, throat or tongue suddenly become swollen; breathing very fast or struggling to breathe (wheezing, choking or gasping); throat feels tight or difficulty swallowing; skin, tongue or lips turn blue, grey or pale (on black or brown skin this may be easier to see on the palms or soles); suddenly becoming very confused, drowsy or dizzy; fainting and not being woken up; a child being limp, floppy or not responding as usual. There may also be a swollen, raised, itchy, blistered or peeling rash.

Action: Call 999 now. Do not drive yourself to A&E; the person you speak to at 999 will advise what to do. (4)

Chest pain that may be a heart attack — emergency

Symptoms: Chest pain that does not stop after a few minutes, or is new or worse if you already have angina.

Action: Call 999 now. If you have been diagnosed with angina and get chest pain, follow the instructions you have been given: stop and rest, use any medicine prescribed (usually glyceryl trinitrate), take another dose after 5 minutes if the first does not help, and if symptoms remain 5 minutes after the second dose call 999 for an ambulance. Do not drive yourself to A&E. (4)

Angina worsening and heart attack after abrupt discontinuation — serious

Symptoms: US labelling reports angina exacerbation and myocardial infarction after abrupt discontinuation of propranolol.

Action: Reduce gradually over at least a few weeks and do not stop without the physician's advice. Do not stop taking propranolol without talking to a doctor; stopping suddenly may cause serious heart problems. (2) (3)

Masking of hypoglycemia signs — serious

Symptoms: Propranolol may mask the premonitory signs of acute hypoglycemia, especially in labile insulin-dependent diabetes, and has been associated with hypoglycemia particularly in infants and children.

Action: Speak to your doctor if you have low blood sugar levels without the usual warning signs. Check blood sugar after exercise and follow usual advice about checking it before driving, cycling or operating machinery. (2) (4)

Masking of hyperthyroidism and thyroid storm on withdrawal — serious

Symptoms: Propranolol may mask the signs of hyperthyroidism; abrupt withdrawal may precipitate thyroid storm.

Action: Discuss any planned changes to treatment with the prescriber rather than changing it yourself. (2)

Hypersensitivity and skin reactions — serious

Symptoms: US labelling reports hypersensitivity and skin reactions including Stevens-Johnson syndrome.

Action: Seek medical attention promptly if a serious skin or allergic reaction is suspected; let the clinician you see advise on whether to continue or stop. (2)

Interactions

Medicine or test	Effect	Action
Other medicines for high blood pressure	The combination with propranolol can sometimes lower blood pressure too much, which may make you feel dizzy or faint.	If this keeps happening, your doctor may change your dose. (4)
Other medicines for an irregular heartbeat (such as amiodarone, digoxin or flecainide)	US labelling notes additive effects with propafenone and amiodarone, and advises caution with drugs slowing AV conduction (digitalis, calcium channel blockers).	Tell your doctor or pharmacist if you are taking any of these. (2) (4)
Other medicines that can lower blood pressure	Includes some antidepressants, nitrates (for chest pain), baclofen (a muscle relaxant), medicines for an enlarged prostate like tamsulosin, or Parkinson's disease medicines such as levodopa.	Tell your doctor or pharmacist if you are taking any of these. (4)
Drugs affecting CYP2D6, 1A2 or 2C19	US labelling lists interactions with drugs affecting these enzymes.	Give the prescriber and pharmacist a complete list of medicines. (2)
Quinidine	Quinidine increases propranolol levels, with postural hypotension reported.	Tell your doctor or pharmacist if you are taking quinidine. (2)
Lidocaine	Propranolol reduces lidocaine clearance; lidocaine toxicity has been reported.	Tell your doctor or pharmacist if you are taking lidocaine. (2)
Asthma or COPD medicines	Propranolol works differently from other beta blockers in that it does not just affect the heart; it can affect other parts of the body too, such as the lungs.	Tell your doctor or pharmacist if you are taking any of these. (4)
Diabetes medicines, particularly insulin	Propranolol may make it more difficult to recognise the warning signs of low blood sugar.	Speak to your doctor if you have low blood sugar levels without the usual warning signs. Check your blood sugar after exercise and follow usual advice about checking it before driving, cycling or operating machinery. (4)
Medicines to treat nose or sinus congestion, or other cold remedies (including pharmacy-bought ones)	Listed as medicines that may affect the way propranolol works.	Tell your doctor or pharmacist if you are taking any of these. (4)
Medicines for allergies such as ephedrine, noradrenaline or adrenaline	Listed as medicines that may affect the way propranolol works.	Tell your doctor or pharmacist if you are taking any of these. (4)
NSAIDs such as ibuprofen, diclofenac or naproxen	These medicines may increase your blood pressure.	It is best to keep them to a minimum. (4)
Rizatriptan for migraines	Listed as a medicine that may affect the way propranolol works.	Tell your doctor or pharmacist if you are taking rizatriptan. (4)
Herbal remedies and supplements	There is very little information about taking herbal remedies and supplements with propranolol; they are not tested in the same way as pharmacy and prescription medicines and are generally not tested for their effect on other medicines.	Tell your doctor or pharmacist if you are taking any other medicines, including herbal remedies, vitamins or supplements. (4)

Special populations

Children and adolescents

Most adults and children aged 12 years and over can take propranolol. A doctor may prescribe it for children under 12 years old for high blood pressure, but it is not licensed for this. If your child needs propranolol, your doctor will usually use your child's weight to work out the right dose. (4)

Adults aged over 65

Doses are usually lower for people aged over 65. (4)

Pregnancy

UK information states you can take propranolol during pregnancy, and that it can sometimes affect the baby's growth, with extra growth scans offered in later pregnancy (usually from 32 weeks). US labelling states there are no adequate well-controlled human studies; intrauterine growth retardation, small placentas and congenital abnormalities have been reported in babies of mothers who took propranolol, and babies exposed at delivery have shown slow heart rate, low blood sugar and breathing depression; use in pregnancy only if the potential benefit justifies the potential risk to the fetus, which is a decision for the prescriber. If you are trying to get pregnant or are already pregnant, talk to your doctor about whether taking propranolol is right for you, or whether a different medicine might be better. (2) (4)

Breastfeeding

UK information states that if your baby is healthy it is OK to take propranolol while breastfeeding, and that propranolol passes into breast milk in tiny amounts and has not been known to cause side effects in breastfed babies; always check with a pharmacist or doctor before taking it. It is important to keep taking propranolol to keep you well. Contact your healthcare professional or call 111 as soon as possible if you notice the baby is not feeding as well as usual or not putting on weight as expected, seems unusually sleepy, tired or weak, looks much paler than usual, seems sweaty or shaky, has changes in breathing, or has an upset stomach. US labelling states propranolol is excreted in human milk and caution should be exercised; discuss with the prescriber. (2) (4)

Fertility

There is no evidence that propranolol affects fertility in men or women. If you are trying to get pregnant, or are having problems getting pregnant while on propranolol, speak to your doctor. (4)

Kidney problems

US labelling states that in chronic renal failure, propranolol peak plasma levels were 2 to 4 times higher and clearance was reduced versus healthy subjects, and that propranolol is not significantly dialysable. The label gives no specific renal dose adjustment; the prescriber individualises the dose and may monitor more closely. UK information notes doses are usually lower for people with kidney problems. (2) (4)

Liver problems

Propranolol undergoes high first-pass hepatic metabolism (only about 25% reaches the circulation). The label gives no specific hepatic dose adjustment; the prescriber individualises the dose. UK information notes doses are usually lower for people with liver problems. (2) (4)

Driving, cycling and machinery

Propranolol can make some people feel dizzy, especially when first starting it or after taking a bigger dose. If this happens, do not drive a car, ride a bike, or use tools or machinery. It is an offence to drive a car if your ability to drive safely is affected, and it is your responsibility to decide if it is safe to drive; if in doubt, do not drive. Talk to your doctor or pharmacist if unsure. (4)

Alcohol

Drinking alcohol can increase the blood pressure-lowering effect of propranolol, which can make you feel dizzy or lightheaded. During the first few days of taking propranolol or after a dose increase, it is best to stop drinking alcohol until you see how the medicine affects you. If propranolol makes you feel dizzy, it is best to stop drinking alcohol. (4)

Contraception

Propranolol will not stop your contraception working. However, some types of hormonal contraception, like the combined pill and contraceptive patch, are not usually recommended if you are taking propranolol or other medicines for high blood pressure, because some hormonal contraceptives can raise blood pressure and stop propranolol working properly. Talk to your doctor if you are taking a hormonal contraceptive. If propranolol makes you sick or gives you severe, watery diarrhoea or diarrhoea lasting more than 24 hours, your contraceptive pills may not protect you from pregnancy; check the pill packet for advice. (4)

Sports

You do not need to stop playing sports if you take propranolol; talk to your doctor or pharmacist for advice. Regular exercise is good for you because it lowers blood pressure. Be aware that in some sports propranolol is not allowed if you are competing at a high level. (4)

Surgery and general anaesthetic

Tell your doctor that you are taking propranolol if you are going to be put to sleep using general anaesthetic, or are having any kind of major operation. Your doctor may advise you to stop taking propranolol before surgery, because propranolol can lower blood pressure too much when combined with some anaesthetics. US labelling notes chronic beta-blockade should not routinely be withdrawn before major surgery. (2) (4)

Food and drink

Apart from being careful with alcohol, you can eat and drink normally while taking propranolol. Eating a healthy, balanced diet can help if you have high blood pressure or another heart condition. (4)

Monitoring

Before starting

Confirm the exact reason for use, local eligibility and background treatment, and check the contraindication and caution list against the exact local label.
Assess blood pressure, heart rate, heart failure status, asthma or lung disease, circulation problems (such as Raynaud's), diabetes, liver or kidney problems, metabolic acidosis, history of depression or thoughts of self-harm, and pheochromocytoma.
Review all other medicines, including other blood-pressure medicines, heart-rhythm medicines, asthma or COPD medicines, diabetes medicines, cold remedies, allergy medicines, NSAIDs, rizatriptan, herbal remedies and supplements.
Confirm pregnancy, plans for pregnancy, or breastfeeding status and discuss with the prescriber.

During treatment

Blood pressure should be checked regularly if propranolol is taken long term for migraines or anxiety.
Blood sugar should be checked after exercise, and usual advice followed about checking it before driving, cycling or operating machinery, particularly if you have diabetes.
Reassess symptom control, side effects, and continued suitability, including whether the dose needs review for older people or people with kidney or liver problems.
If a migraine-prevention trial is not satisfactory within 4 to 6 weeks of reaching the maximum dose, the prescriber may stop the treatment (US labelling).

(2) (4)

Storage

Follow the exact product label and keep medicines away from children.

Professional information

Clinician-facing context only. Use the current local indication, dosing table, formulation and device instructions, and local guideline. US and UK labelling differ and must not be blended; where a statement is country-specific it is marked as such.

United States

Indication: Hypertension

Dose summary: Usually 40 mg twice daily initially; maintenance 120–240 mg/day; some patients need up to 640 mg/day. Dose must be individualised because bioavailability varies.

Renal context: No specific renal dose adjustment is given in the label; the prescriber individualises and may monitor more closely. (2)