Propranolol: 7 things you should know

Medically reviewed by Carmen Fookes, BPharm. Last updated on Dec 30, 2022.

1. How it works

• Propranolol is a medicine that may be used to treat certain heart conditions, reduce essential tremor, or prevent migraine. It works by blocking beta receptors. There are two types of beta receptors, beta-1 receptors (located in the heart) and beta-2 receptors (located in the bronchioles of the lungs and the arteries of skeletal muscle).
• Propranolol blocks beta-1 receptors in the heart which slows the heart rate and decreases how hard the heart has to work to pump blood around the body, decreasing blood pressure.
• Propranolol has a "nonselective" action. This means that it also blocks beta-2 receptors in the bronchioles, which can cause a narrowing of the bronchioles which may cause breathing difficulties in people with pre-existing lung disease.
• Propranolol also has a membrane-stabilizing effect at higher dosages which can affect the electrical impulses of the heart, although is not thought to contribute much to its antiarrhythmic properties.
• Experts are not sure how propranolol works to prevent migraines or tremors.
• Propranolol belongs to a class of medicines known as beta-adrenergic blockers or beta-blockers.

2. Upsides

• May be used to treat high blood pressure (hypertension), either alone or in combination with thiazide diuretics or other medicines for hypertension.
• May improve the symptoms of angina and increase a person with angina's capacity to exercise.
• May be used in the prevention of migraine headaches.
• May improve symptoms of hypertrophic subaortic stenosis; however, will not change the course of the disease.
• Approved for the treatment of essential tremor (ET). Reduces tremor amplitude but not frequency; complete suppression of tremor is rare. Appears to work best for high-amplitude, low-frequency ET.
• Generic propranolol is available.

3. Downsides

If you are between the ages of 18 and 60, take no other medication or have no other medical conditions, side effects you are more likely to experience include:

• Low blood pressure (which may be felt as dizziness upon standing); cold extremities or Raynaud's phenomenon (characterized by numbness and cold in the fingers and toes in response to cold temperatures or stress); tiredness or lack of energy; a slow heart rate and irritability are some of the more commonly reported side effects. Elderly people may be more sensitive to these effects.
• Propranolol is more likely than some other beta-blockers (such as atenolol) to cause vivid or unusual dreams.
• Abrupt discontinuation has been associated with exacerbation of angina, and rarely, heart attacks. Only discontinue on a doctor's advice and reduce dosage gradually over a few weeks.
• May not be suitable for some people including those with certain heart or respiratory conditions, or those with kidney or liver disease. Propranolol may interfere with glaucoma screening tests because it can reduce intraocular pressure.
• Can mask the symptoms of hypoglycemia (low blood sugar) or hyperthyroidism (high thyroid levels), so must be used with caution in people with diabetes or thyroid disease.
• May aggravate peripheral circulatory disorders, increase blood cholesterol levels, and decrease HDL cholesterol.
• May cause several unwanted heart-related effects and may affect breathing, so the response must be monitored. May cause low blood sugar (hypoglycemia) even in people without diabetes and interfere with some laboratory tests.
• Can interact with several different drugs including several drugs used to treat heart conditions, NSAIDs, antidepressants, anesthetic agents, warfarin, and those metabolized through CYP2D6, 1A2, or 2C19 metabolic pathways.
• Should only be used during pregnancy if the benefits outweigh the risks. Beta-blockers, such as propranolol, may cause decreased placental perfusion, fetal and neonatal bradycardia, and hypoglycemia. But propranolol has been used safely to treat a variety of conditions during pregnancy, including hypertension and pheochromocytoma in the mother, and tachyarrhythmias in both the mother and fetus. Research suggests there may be a risk of delayed intrauterine growth, small placentas, polycythemia, thrombocytopenia, and hypocalcemia with propranolol use during pregnancy. Passes into breastmilk. While no adverse effects in the nursing infant have been reported, experts advise monitoring the infant for signs and symptoms of beta-blockade and to schedule feedings at least 3 hours after maternal propranolol administration, if the woman desires to continue breastfeeding.

Note: In general, seniors or children, people with certain medical conditions (such as liver or kidney problems, heart disease, diabetes, seizures) or people who take other medications are more at risk of developing a wider range of side effects. View complete list of side effects

4. Bottom Line

Propranolol is mainly used for blood pressure and angina control; however, it also has a role in migraine prevention and the treatment of essential tremor. Propranolol may cause vivid dreams and is not usually recommended for people with pre-existing breathing difficulties.

5. Tips

• May be taken with or without food. Take exactly as directed. Do not increase or decrease the dosage without your doctor's advice.
• Swallow extended-release capsules whole: do not prise apart or chew.
• Should always be used as part of a comprehensive cardiovascular risk reduction program that includes diabetes management, smoking cessation, exercise, and other drug therapies. May be used in addition to other blood pressure-lowering drugs.
• Seek immediate medical advice if you find it difficult to breathe.
• Talk to your doctor as soon as possible if any new numbness, pain, skin color changes, or sensitivity occurs in your fingers or toes.
• Call your doctor immediately if you develop a severe skin rash or painful blisters anywhere on your body.
• If you have diabetes, and you have been prescribed propranolol, be aware that it may mask some of the signs or symptoms of hypoglycemia (low blood sugar levels), such as heart palpitations and shakiness.
• Propranolol may also cause blood sugar levels to drop in people without diabetes, particularly after exercise or exertion, or in those who have kidney disease. This may be felt as light-headedness or dizziness.
• Tell your doctor if you are pregnant, intending to become pregnant, or breastfeeding because propranolol may not be suitable for you.

6. Response and effectiveness

• Peak concentrations are reached within six hours following administration of extended-release (ER) capsules; effects last for 24 hours following ER dosing so ER capsules may be given once daily.
• Propranolol is lipophilic and can cross the blood/brain barrier (a semipermeable membrane that separates blood from the fluid surrounding the brain). This means it is more likely than some water-soluble beta-blockers (such as atenolol) to cause side effects such as vivid or unusual dreams.
• When used for essential tremor, there is a wide variation in individual response, and effective dosages may range from 60mg to 320mg. May be used daily or as needed before or during social situations or planned events.

7. Interactions

Medicines that interact with propranolol may either decrease its effect, affect how long it works, increase side effects, or have less of an effect when taken with propranolol. An interaction between two medications does not always mean that you must stop taking one of the medications; however, sometimes it does. Speak to your doctor about how drug interactions should be managed.

Common medications that may interact with propranolol include:

• Albuterol
• Antidepressants, such as fluoxetine, paroxetine, St John’s Wort, and monoamine oxidase inhibitors
• Antifungals, such as fluconazole
• Antihistamines, such as diphenhydramine
• Bupropion, which may be used for the treatment of depression and as a stop-smoking aid
• Epinephrine
• Fingolimod, which may be used for the treatment of multiple sclerosis
• HIV medications such as ritonavir or delavirdine
• Indigestion and heartburn medications, such as cimetidine and ranitidine
• Some medications used to treat mental illness, such as haloperidol or thioridazine
• Some heart medications, such as amiodarone, clonidine, digoxin, diltiazem, propafenone, quinidine, and verapamil
• Other medications including celecoxib, hydralazine, and rifampicin
• NSAIDs, such as diclofenac, ibuprofen, and indomethacin, may decrease the blood pressure-lowering capabilities of propranolol.

People taking oral medications for diabetes may need to talk to their doctor about adjusting the dose of their medicine.

Note that this list is not all-inclusive and includes only common medications that may interact with propranolol. You should refer to the prescribing information for propranolol for a complete list of interactions.

References

• Propranolol. Revised 09/2022. Lannett Company, Inc. https://www.drugs.com/pro/propranolol.html

Further information

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use propranolol only for the indication prescribed.

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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