propranolol hydrochloride

(proe pran' oh lole)

Apo-Propranolol (CAN), Inderal, Inderal LA, InnoPran XL, Novopranol
(CAN), PMS-Propranolol (CAN)

Pregnancy Category C

Drug classes
Beta-adrenergic blocker (nonselective)
Antianginal
Antiarrhythmic
Antihypertensive

Therapeutic actions
Competitively blocks beta-adrenergic receptors in the heart and juxtoglomerular
apparatus, decreasing the influence of the sympathetic nervous system on these tissues,
the excitability of the heart, cardiac workload and oxygen consumption, and the release
of renin and lowering BP; has membrane-stabilizing (local anesthetic) effects that
contribute to its antiarrhythmic action; acts in the CNS to reduce sympathetic outflow and
vasoconstrictor tone. The mechanism by which it prevents migraine headaches is
unknown.

Indications
• Hypertension alone or with other drugs, especially diuretics
• Angina pectoris caused by coronary atherosclerosis
• IHSS to manage associated stress-induced angina, palpitations, and syncope
• Cardiac arrhythmias, especially supraventricular tachycardia, and ventricular
tachycardias induced by digitalis or catecholamines
• Prevention of reinfarction in clinically stable patients 5–21 days after MI
• Pheochromocytoma, an adjunctive therapy after treatment with an alpha-
adrenergic blocker to manage tachycardia before or during surgery or if the
pheochromocytoma is inoperable
• Prophylaxis for migraine headache
• Treatment of essential tremor, familial or hereditary
• Unlabeled uses: Recurrent GI bleeding in cirrhotic patients, schizophrenia, tardive
dyskinesia, acute panic symptoms

Contraindications and cautions

• Contraindicated with allergy to beta-blocking agents, sinus bradycardia, second-
or third-degree heart block, cardiogenic shock, CHF, bronchial asthma,
bronchospasm, COPD, pregnancy (neonatal bradycardia, hypoglycemia, and
apnea, and low birth weight with long-term use during pregnancy), lactation.
• Use cautiously with hypoglycemia and diabetes, thyrotoxicosis, hepatic
dysfunction.
Available forms
ER capsules—60, 80, 120, 160 mg; tablets—10, 20, 40, 60, 80, 90 mg; SR capsules—60,
80, 120, 160 mg; injection—1 mg/mL; oral solution—4, 8 mg/mL; concentrated oral
solution—80 mg/mL

Dosages
ADULTS
Oral
• Hypertension: 40 mg regular propranolol bid or 80 mg sustained-release (SR)
daily initially; usual maintenance dose, 120–240 mg/day given bid or tid or 120–
160 mg SR daily (maximum dose, 640 mg/day).
• Angina: 80–320 mg/day divided bid, tid, or qid or 80 mg SR daily initially;
gradually increase dosage at 3- to 7-day intervals; usual maintenance dose,
160 mg/day (maximum dose, 320 mg/day).
• IHSS: 20–40 mg tid or qid or 80–160 mg SR daily.
• Arrhythmias: 10–30 mg tid or qid.
• MI: 180–240 mg/day given tid or qid (maximum dose, 240 mg/day).
• Pheochromocytoma: Preoperatively, 60 mg/day for 3 days in divided doses;
inoperable tumor, 30 mg/day in divided doses.
• Migraine: 80 mg/day daily (SR) or in divided doses; usual maintenance dose,
160–240 mg/day.
• Essential tremor: 40 mg bid; usual maintenance dose, 120 mg/day.
• Situational anxiety: 40 mg, timing based on the usual onset of action (maximum
dose, 320 mg/day).
Parenteral
Note: IV dose is markedly less than oral because of first-pass effect with oral propranolol.
• Life-threatening arrhythmias: 1–3 mg IV with careful monitoring, not to exceed
1 mg/min; may give second dose in 2 min, but then do not repeat for 4 hr.
PEDIATRIC PATIENTS
Safety and efficacy not established.

Pharmacokinetics
Route Onset Peak Duration
Oral 20–30 min 60–90 min 6–12 hr
IV Immediate 1 min 4–6 hr

Metabolism: Hepatic; T1/2: 3–5 hr; 8–11 hr (SR form)

Distribution: Crosses placenta; enters breast milk
Excretion: Urine

IV facts
Preparation: No further preparation is needed.
Infusion: Inject directly IV or into tubing of running IV; do not exceed 1 mg/min.

Adverse effects
 • Allergic reactions: Pharyngitis, erythematous rash, fever, sore throat,
laryngospasm, respiratory distress
• CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias,
sleep disturbances, hallucinations, disorientation, memory loss, slurred speech
• CV: Bradycardia, CHF, cardiac arrhythmias, sinoatrial or AV nodal block,
peripheral vascular insufficiency, claudication, CVA, pulmonary edema,
hypotension
• Dermatologic: Rash, pruritus, sweating, dry skin
• EENT: Eye irritation, dry eyes, conjunctivitis, blurred vision
• GI: Gastric pain, flatulence, constipation, diarrhea, nausea, vomiting, anorexia,
ischemic colitis, renal and mesenteric arterial thrombosis, retroperitoneal fibrosis,
hepatomegaly, acute pancreatitis
• GU: Impotence, decreased libido, Peyronie's disease, dysuria, nocturia, frequency
• Musculoskeletal: Joint pain, arthralgia, muscle cramp
• Respiratory: Bronchospasm, dyspnea, cough, bronchial obstruction, nasal
stuffiness, rhinitis, pharyngitis
• Other: Decreased exercise tolerance, development of ANAs, hyperglycemia or
hypoglycemia, elevated serum transaminase, alkaline phosphatase, and LDH

Interactions
Drug-drug
• Increased effects with verapamil
• Decreased effects with indomethacin, ibuprofen, piroxicam, sulindac, barbiturates
• Prolonged hypoglycemic effects of insulin
• Initial hypertensive episode followed by bradycardia with epinephrine
• Increased first-dose response to prazosin
• Increased serum levels and toxic effects with lidocaine, cimetidine
• Increased serum levels of propranolol and phenothiazines, hydralazine if the two
drugs are taken concurrently
• Paradoxical hypertension when clonidine is given with beta-blockers; increased
rebound hypertension when clonidine is discontinued in patients on beta-blockers
• Decreased serum levels and therapeutic effects with methimazole,
propylthiouracil
• Decreased bronchodilator effects of theophyllines
• Decreased antihypertensive effects with NSAIDs (ie, ibuprofen, indomethacin,
piroxicam, sulindac), rifampin

Drug-lab test
• Interference with glucose or insulin tolerance tests, glaucoma screening tests

Nursing considerations
Assessment
• History: Allergy to beta-blocking agents, sinus bradycardia, second- or third-
degree heart block, cardiogenic shock, CHF, bronchial asthma, bronchospasm,
 COPD, hypoglycemia and diabetes, thyrotoxicosis, hepatic dysfunction,
pregnancy, lactation
• Physical: Weight, skin color, lesions, edema, T; reflexes, affect, vision, hearing,
orientation; BP, P, ECG, peripheral perfusion; R, auscultation; bowel sounds,
normal output, liver evaluation; bladder palpation; liver and thyroid function tests;
blood and urine glucose

Interventions
• Do not discontinue drug abruptly after long-term therapy (hypersensitivity to
catecholamines may have developed, causing exacerbation of angina, MI, and
ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring.
• Ensure that alpha-adrenergic blocker has been given before giving propranolol
when treating patients with pheochromocytoma; endogenous catecholamines
secreted by the tumor can cause severe hypertension if vascular beta receptors are
blocked without concomitant alpha blockade.
• Consult with physician about withdrawing drug if patient is to undergo surgery
(withdrawal is controversial).
• Provide continuous cardiac and regular BP monitoring with IV form. Change to
oral form as soon as possible.
• Give oral drug with food to facilitate absorption.

Teaching points
• Take this drug with meals. Do not discontinue the medication abruptly; abrupt
discontinuation can cause a worsening of your disorder.
• These side effects may occur: Dizziness, drowsiness, light-headedness, blurred
vision (avoid driving or performing hazardous tasks); nausea, loss of appetite (eat
frequent small meals); nightmares, depression (request change of your
medication); sexual impotence.
• Report difficulty breathing, night cough, swelling of extremities, slow pulse,
confusion, depression, rash, fever, sore throat.
• If you have diabetes, the normal signs of hypoglycemia (tachycardia) may be
blocked by this drug; monitor your blood or urine glucose carefully; eat regular
meals, and take your diabetic medication regularly.

Adverse effects in Italic are most common; those in Bold are life-threatening.