Propranolol HCl

A to Z Drug Facts

(pro-PRAN-oh-lahl HIGH-droe-KLOR-ide)

Betachron E-R, Inderal, Inderal LA, Propranolol Intensol,  APO-Propranolol, Detensol, Detensol, Dom-Propranolol, Novo-Pranol, Nu-Propranolol, PMS-Propranolol

Class: Beta-adrenergic blocker

 Action Blocks beta receptors, primarily affecting the cardiovascular system (decreased heartrate, decreased cardiac contractility and decreased BP) and lungs (promotes bronchospasm).

 Indications Treatment of hypertension; angina pectoris; hypertrophic subaortic stenosis; MI; pheochromocytoma; migraine prophylaxis; essential tremor; some ventricular and supraventricular arrhythmias. Unlabeled use(s): Treatment of alcohol withdrawal syndrome; esophageal varices rebleeding; anxiety; thyrotoxicosis symptoms.

 Contraindications Hypersensitivity to beta-blockers; greater than first-degree heart block; CHF unless secondary to tachyarrhythmia or untreated hypertension treatable with beta-blockers; overt cardiac failure; sinus bradycardia; cardiogenic shock; untreated bronchial asthma or bronchospasm, including severe COPD.

 Route/Dosage

Hypertension

ADULTS: PO Initial dose: 40 mg bid initially or 80 mg sustained-release medication/day; titrate to response. Maintenance: 120 to 240 mg/day in 2 to 3 divided doses or 120 to 160 mg/day sustained-release medication. Do not exceed 640 mg/day. CHILDREN: PO 0.5 mg/kg bid; titrate q 3 to 5 days to maximum dose of 1 mg/kg bid.

Angina

ADULTS: PO 80 to 320 mg/day in 2 to 4 divided doses or 160 mg/day of sustained-release medication.

Arrhythmias

ADULTS: PO 10 to 30 mg 3 to 4 times/day before meals and at bedtime.

Hypertrophic Aortic Stenosis

ADULTS: PO 20 to 40 mg 3 to 4 times/day before meals and at bedtime or 80 to 160 mg sustained-release medication 1 time/day.

MI

ADULTS: PO 180 to 240 mg/day in 3 to 4 divided doses up to 240 mg/day.

Pheochromocytoma

ADULTS: PO 60 mg/day for 3 days prior to surgery, given with alpha-blocker.

Migraine

ADULTS: PO 80 mg in divided doses daily or once daily (sustained release); titrate to response (maximum dose: 240 mg/day); discontinue after 6 wk if no response.

Arrhythmias (Life Threatening)

ADULTS: IV 1 to 3 mg at rate of 1 mg/min; may repeat after 2 min; give subsequent doses q 4 hr.

Essential Tremor

ADULTS: PO 40 mg bid initially; titrate to response. Maintenance: 120–320 mg/day in 2 to 3 divided doses.

 Interactions

Barbiturates: Decreased bioavailability of propranolol. Cimetidine: Increased propranolol levels. Clonidine: Attenuation or reversal of antihypertensive effect; potentially life-threatening increases in BP, especially on withdrawal. Epinephrine: Initial hypertensive episode followed by bradycardia. Ergot alkaloids: Peripheral ischemia, manifested by cold extremities and possible gangrene. Hydralazine: Increased serum levels of both drugs. Insulin: Prolonged hypoglycemia with masking of symptoms. Lidocaine: Increased lidocaine levels, leading to toxicity. NSAIDs: Some agents may impair antihypertensive effect. Phenothiazines: Increased effects of either drug. Prazosin: Increased orthostatic hypotension. Propafenone, quinidine, thioamines: Increased effects of propranolol. Rifampin: Decreased effects of propranolol. Theophylline: Reduces elimination of theophylline; pharmacologic antagonism. Verapamil: Increased effects of both drugs.

 Lab Test Interferences May interfere with glaucoma screening tests; may increase BUN, serum transaminases, alkaline phosphatase or LDH.

 Adverse Reactions

CV: Bradycardia; hypotension; CHF; atrioventricular (AV) block; worsening angina; torsades de pointes; edema; peripheral ischemia. CNS: Depression; tiredness; fatigue; lethargy; sleep disturbances;. bizarre dreams; short-term memory loss; dizziness. DERM: Rash; pruritus. EENT: Dry eyes; visual disturbances. GI: Dyspepsia; nausea; vomiting; diarrhea; dry mouth. GU: Impotence; urinary retention; difficulty with urination. HEMA: Agranulocytosis. HEPA: Elevated liver enzymes. META: Hyperglycemia; hypoglycemia. RESP: Wheezing; dyspnea; bronchospasm; difficulty breathing. OTHER: Increased sensitivity to cold (Raynaud's phenomenon); psoriasis-like eruptions; skin necrosis; systemic lupus erythematosus; decreased exercise tolerance.

 Precautions

Pregnancy: Category C. Lactation: Excreted in breast milk. Children: Safety and efficacy not established. IV use is not recommended, but oral propranolol has been used. Abrupt withdrawal: A beta-blocker withdrawal syndrome (eg, hypertension, tachycardia, anxiety, angina, MI) may occur 1 to 2 weeks after sudden discontinuation of systemic beta blockers. If possible, gradually withdraw therapy over 1 to 2 weeks. Anaphylaxis: Deaths have occurred; aggressive therapy may be required. CHF: Should be administered cautiously in patients whose CHF is controlled by digitalis and diuretics. Diabetes mellitus: May mask symptoms of hypoglycemia (eg, tachycardia, BP changes). May potentiate insulin-induced hypoglycemia. Nonallergic bronchospastic diseases: Give drug with caution in patients with bronchospastic diseases. Peripheral vascular disease: May precipitate or aggravate symptoms of arterial insufficiency. Renal/Hepatic impairment: Dose should be reduced. Thyrotoxicosis: May mask clinical signs (eg, tachycardia) of developing or continuing hyperthyroidism. Abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm. Wolff-Parkinson-White syndrome: In several cases, tachycardia was replaced by severe bradycardia requiring a demand pacemaker.

 Administration/Storage

• Administer consistently either with or without food.
• Patients who are taking sustained-released capsules should swallow them whole; instruct patient not to bite, open or chew capsules.
• Administer via IV route only in cases of life-threatening arrhythmias or those occurring under anesthesia and only under careful monitoring (eg, central venous pressure, ECG).
• Store tablets/capsules/oral solution at room temperature in tight, light-resistant containers.
• Protect injectable solution from light.
• Administer IV form undiluted or diluted with 10 ml D5W for Injection. Give 1 mg or less/min; may be diluted in 50 ml sodium chloride and 1 mg given over 10 to 15 min.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies. Note diabetes; respiratory, liver or cardiac disease or sensitivity to other beta blockers.
• Review baseline ECG.
• Assess pulse and BP before and during administration. If pulse rate is below 60 bpm or if patient hypotensive, withhold medication and notify physician.
• If renal damage is present, obtain creatinine clearance.
• Obtain hepatic enzyme levels before and during administration.
• Monitor I&O and daily weight during therapy for signs of fluid retention.
• Monitor for headache, light-headedness and decreased BP, which may indicate need for reduced dosage.
• If sudden severe dyspnea or edema of hands and feet develops, withhold medication and notify physician.
• If chest pain occurs, assess for location, intensity, duration and radiation, and notify physician.

 Patient/Family Education

• Explain that dosage will be tapered slowly before stopping. Warn that sudden discontinuation can cause chest pain or heart attack.
• Instruct patient to take medication at same time each day.
• Teach patient how to take pulse and instruct to check before taking drug. Warn patient not to take drug if pulse is less than usual rate (or < 60 bpm) and to call physician.
• Educate patient or family to take BP and advise to take on regular basis.
• Inform diabetic patient to monitor blood glucose level carefully.
• Instruct patient to report the following symptoms to physician: Difficulty breathing, night cough, slowed pulse rate, dizziness, rash, fever, sore throat, confusion, depression, drowsiness, unusual bruising, or bleeding.
• Caution patient to avoid sudden position changes to prevent orthostatic hypotension.
• Advise patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.
• Instruct patient not to take otc medications (including nasal decongestants, diet aids, or cold preparations) without consulting physician.

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Copyright © 2003 Facts and Comparisons
David S. Tatro
A to Z Drug Facts