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Drug Monograph

Propranolol

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Propranolol

Non-selective Ξ²1/Ξ²2 blocker

AdultBBHigh Yield

Indication

Portal HTN (varices) β€’ Thyrotoxicosis (adjunct) β€’ Migraine prevention β€’ HTN / angina β€’ AF rate (non-asthmatic)

At a glance

INDICATIONS (CORE USE)

**Non-selective** β€” **DO NOT use** in asthma / active bronchospasm. Portal HTN, thyrotoxicosis adjunct, migraine prevention, HTN/angina where appropriate.

ADULT DOSE (STANDARD)

**PO:** **start low** (e.g. **20–40 mg** divided) β†’ titrate β€” **portal/migraine** targets differ from HTN **IV** (acute thyroid storm protocols only β€” institutional)

MAX DOSE

**Indication-specific** β€” portal and migraine regimens differ; **titration** is clinical

Route

PO; IV rare (acute thyroid storm β€” protocol)

PEDIATRIC DOSE

Specialist β€” infantile hemangioma / other protocols

Do not miss

Must-not-miss safety points

Major warning

- DO NOT use in asthma / active bronchospasm - DO NOT use in stimulant (e.g. cocaine) chest pain due to unopposed alpha vasospasm risk - Bradycardia / AV block - Severe OD β€” seizures / CNS (lipophilic)

Indications

USE IF: Portal HTN prophylaxis, thyrotoxicosis with Ξ±-blockade first for storm, migraine prevention, HTN when non-selective acceptable. AVOID IF: Asthma with bronchospasm, cocaine/stimulant-related coronary syndrome without specialist plan.

Primary

  • Hypertension (when non-selective Ξ²-blockade acceptable)

Secondary

  • Atrial fibrillation β€” **rate control**
  • Angina / chronic ischemic heart disease

Other

  • **Portal hypertension** β€” esophageal variceal bleed **prophylaxis** (gastroenterology dosing)
  • **Thyrotoxicosis** β€” adjunct (often with **Ξ±-blockade** first in **storm**)
  • **Migraine** prevention

Dosing

STANDARD (ADULT PO)

**BID–QID** IR or **QD** LA depending on formulation

ADULT DOSE

**HTN/angina:** **20–40 mg** BID start β†’ titrate. **Migraine prevention:** lower-and-slow titration per neurology. **Portal:** follow **GI** protocol doses β€” not interchangeable with HTN titration.

PEDIATRIC DOSE

Hemangioma / other β€” specialist dosing.

MAX DOSE

Wide range by indication β€” follow **protocol**, not one max for all uses

Practical Note

**LA capsule** β€” do not crush. **Portal HTN:** titrate to HR ~55–60 bpm or ~25% reduction from baseline (specialist protocol).

Warnings

Clinical warnings

  • Non-selective beta-blockade β€” **DO NOT use** in asthma / active bronchospasm. **DO NOT use** in stimulant (e.g. cocaine) chest pain due to unopposed alpha vasospasm risk. HOLD if HR <50–55, SBP <90–100, symptomatic bradycardia, high-grade AV block, or acute decompensated HF with shock/hypoperfusion.

Adverse effects

  • Bronchospasm
  • fatigue
  • bradycardia
  • nightmares
  • masked hypoglycemia

Contraindications

  • Severe asthma / active bronchospasm
  • Cardiogenic shock
  • High-grade AV block (without pacing)

Drug interactions

  • Verapamil / diltiazem: avoid or use extreme caution (bradycardia / AV block / hypotension / shock risk)
  • Digoxin: additive AV-node suppression / AV block risk
  • Insulin / sulfonylureas: masks hypoglycemia warning
  • Cimetidine (↑ propranolol levels)

Special populations

Pediatrics

Specialist β€” infantile hemangioma / other protocols

Pregnancy

**Pregnancy:** fetal effects context-dependent β€” OB. **

Lactation

** excreted in milk β€” monitor infant if high dose.

Renal impairment

Hepatic metabolism dominant β€” renal failure less dose impact than atenolol.

Hepatic impairment

**Severe hepatic disease** β€” **↓ dose**; monitor sedation/CNS.

Elderly

Start low β€” hypotension and falls.

Administration

Take with food if GI upset; LA per swallow whole.

Monitoring

  • Monitor: - Symptoms β†’ dizziness, syncope, fatigue - β€’ Lipophilic (e.g. propranolol) β†’ monitor CNS (seizures, coma in severe toxicity) - β€’ Lipophilic / overdose: check glucose early; hypoglycemia may be silent
  • Recheck: - Reassess ECG / PR interval / AV block risk with symptoms, IV use, or dose escalation - Reassess dose / volume / cause within 48–72h after change - If targets not met after reassessment of dose, organ function, and interactions β†’ escalate per protocol (DO NOT continue blindly)
  • Hold if:
    - Hold if:
    - HR <50–55
    - SBP <90–100
    - Symptomatic bradycardia
    - Acute decompensated HF
    - Hypoperfusion / cardiogenic shock
    - Pulmonary edema requiring IV therapy

    Also hold:
    - High-grade AV block
    - Severe orthostasis

Overdose / toxicity

Clinical Picture

A) Mild β†’ bradycardia, hypotension, fatigue B) Moderate β†’ sustained bradycardia + hypotension Β± AV block C) Severe β†’ shock, high-grade AV block, seizures / coma (lipophilic CNS toxicity), wide QRS (Na-channel blockade pattern)

Immediate Actions

β€’ Airway + continuous monitoring first (ABCs, telemetry, BP) β€’ Bradycardia β†’ atropine β€’ Hypotension β†’ IV fluids β€’ Early β†’ IV calcium (CaCl2 / Ca-gluconate) β€’ Glucagon 3–5 mg IV β€’ Repeat or escalate glucagon β†’ infusion if responsive (often transient) β€’ Persistent shock β†’ HIET (insulin + dextrose) β€’ Monitor glucose + potassium closely β€’ Add vasopressors if shock persists β€’ Wide QRS / ventricular arrhythmia β†’ sodium bicarbonate (Na-channel blockade) β€’ Refractory severe lipophilic toxicity / seizures β†’ IV lipid emulsion (toxicology-guided) β€’ Pacing β†’ symptomatic high-grade AV block β€’ ECMO β†’ refractory shock (per center) β€’ Severe / unstable β†’ ACLS + ICU / toxicology

Antidote

- Glucagon β†’ non-Ξ² pathway (often transient) - IV calcium β†’ inotropy / conduction support - HIET β†’ metabolic rescue (refractory shock) - IV lipid β†’ lipophilic toxicity (refractory / seizures)

Decontamination

β€’ Recent **oral** ingestion β†’ **activated charcoal** if **protected airway** and within **~1–2 h** (ingestion history + risk/benefit)

Escalation

- Wide QRS / ventricular arrhythmia β†’ sodium bicarbonate (membrane-stabilizing toxicity) - Pacing β†’ symptomatic high-grade AV block - ECMO β†’ refractory shock (per center)

Clinical pearls

Common mistakes, resistance logic, and bedside traps

High-Yield Summary

Lipophilic non-selective Ξ²-blocker β†’ CNS penetration + higher seizure risk + Na-channel blockade (overdose) **Non-selective** = **asthma risk** + **vasodilator-stimulated coronary** concerns in **stimulant** chest pain β€” get help.

Clinical pearls

**Propranolol crosses BBB** β†’ **higher seizure risk** than many other beta-blockers. **Portal** dosing is **its own algorithm** β€” not HTN doses. *Ξ²-blockers (class):* **Start low, go slow.** **HF:** only **evidence-based agents** (**metoprolol succinate**, **bisoprolol**, **carvedilol**) for **HFrEF GDMT** β€” not all Ξ²-blockers interchangeable. **Rate control (AF)** vs **BP lowering** β€” titrate to the clinical target.

Beta-blocker safety

  • Asthma history in chart flag
  • LA swallow whole

Pharmacy Tool

Preparation Calculator

Propranolol 1 mg/mL oral suspension

suspension Β· oral

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Pharmacokinetics

Hepatic first-pass β€” variable bioavailability; short half-life IR β†’ frequent dosing.

Mechanism of action

**Ξ²1 + Ξ²2** blockade; **lipophilic** β€” CNS penetration.

Common brand names

Saudi Arabia

Inderal, Deralin

Global

Hemangeol, (placeholder β€” verify local formulation)

Common trade names are curated examples only β€” formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

  • Acute **aortic syndromes** and **thyrotoxic storm** are **protocol-driven** β€” Ξ²-blocker choice and targets are **team + guideline** specific.
  • Ξ²-blocker **GDMT for HFrEF** applies only to **evidence-based agents** β€” verify label and cardiology plan before substituting.

References

Saudi Arabia

  • SFDA (Saudi Food & Drug Authority)
  • Saudi National Formulary / MOH (where available)

International

  • WHO Model List of Essential Medicines (verify current edition)
  • US FDA or EU EMA product information (when national SmPC is unavailable)
  • ACC / AHA / HFSA heart failure and hypertension guidance
  • ESC cardiovascular and arrhythmia guidelines where applicable
  • FDA / SFDA product labeling
  • Institutional ICU / toxicology protocols (overdose)
  • ACC / AHA / HFSA heart failure and hypertension guidance
  • ESC cardiovascular and arrhythmia guidelines where applicable
  • FDA / SFDA product labeling
  • Institutional ICU / toxicology protocols (overdose)

Do not miss

  • Teach **not to stop abruptly** after chronic use β€” taper when feasible
  • Titrate to **HR vs BP endpoint** (AF rate control often needs higher exposure than BP alone)
  • Asthma history in chart flag
  • LA swallow whole