Adrenaline
Severe
Textbook
Marked rise in BP.
Adrenaline should not be given to patients receiving β blockers.
Source: KDT 7e · p133
Drug reference
Propranolol
Beta Blocker · Anti-arrhythmic
Also known as Propranolol hydrochloride
START
Confirm indication. Baseline heart rate, BP, ECG, pulmonary function (if asthma/COPD history). Screen for diabetes. Start low (20-40 mg BID).
TYPICAL MAX
640 mg/day (hypertension); 320 mg/day (tremor). Titrate gradually.
STOP IF
HR <50 bpm, SBP <90 mmHg, signs of heart failure, severe bronchospasm, severe depression
WATCH
Heart rate, BP (sitting and standing), weight (heart failure), glucose (diabetics), mood/depression, pulmonary symptoms (asthmatics)
CDSCO approvedSchedule HATC C07AA05
KDIGO 2024 + manufacturer label
- ONSET
- 1h · 30-60 min (oral)
- PEAK
- 2.5h · 1-4 h (IR); 6 h (ER)
- t½
- 4.5h · 3-6 h (IR); 8-10 h (ER)
- DURATION
- 8h · 6-8 h (IR BID-TID); 24 h (ER)
EXCRETION
~96-99% renal (metabolites); hepatic CYP1A2/CYP2D6; <1% unchanged
route + CYP
INTERACTIONS
12 major
SEVERE in our sources
PREGNANCY
FDA PLLR: Crosses placenta. Can cause fetal bradycardia, hypoglycemia, growth restriction. Use lowest effective dose. Monitor fetal heart rate if used near delivery.
FDA category + note
Top interactionssee all 12 →
- AdrenalineSevereTextbookKDT 7e · p133
- AmilorideSevereTextbookKDT 7e
- DigitalisSevereTextbookKDT 7e
- SofosbuvirSevereTextbookHarrison 22e · unknown
Available in India
268 branded formulations and 211 fixed-dose combinations. Look up specific brands in the Drugs workspace.
Mechanism
Propranolol is a non-selective beta-adrenergic receptor antagonist (beta-blocker) that competitively blocks both beta-1 (cardiac) and beta-2 (pulmonary/vascular) adrenergic receptors. It has no intrinsic sympathomimetic activity (ISA) and no membrane-stabilizing activity at therapeutic doses. By blocking beta-1 receptors in the heart, it reduces heart rate, myocardial contractility, cardiac output, and renin release. By blocking beta-2 receptors, it prevents bronchodilation and may cause bronchoconstriction in susceptible individuals. It also crosses the blood-brain barrier, which may contribute to its efficacy in migraine prophylaxis and essential tremor, and accounts for CNS side effects (fatigue, depression, vivid dreams). Propranolol has high lipophilicity.
Indications
HypertensionAngina pectorisArrhythmias (atrial fibrillation, ventricular arrhythmias, supraventricular tachycardia)Myocardial infarction (secondary prevention)Migraine prophylaxisEssential tremorHypertrophic subaortic stenosisPheochromocytoma (with alpha-blocker)Performance anxiety / situational anxiety (off-label, short-acting)Infantile hemangioma (oral solution — Hemangeol)
Dosing
- Adult
- Hypertension: 40 mg PO BID initially; titrate by 40-80 mg/day at 3-7 day intervals; usual 120-240 mg/day; max 640 mg/day. Angina: 80-320 mg/day divided BID-TID. Arrhythmia: 10-30 mg PO TID-QID. Migraine: 80-240 mg/day divided BID-TID. Tremor: 40 mg PO BID initially; max 320 mg/day. Anxiety: 10-40 mg PO 1 hour before event.
- Pediatric
- Arrhythmia: 0.5-1 mg/kg/day divided Q6-8h; max 4 mg/kg/day (60 mg/day). Hemangioma (5 weeks-5 months): 0.6 mg/kg/dose BID; titrate to 1.1 mg/kg/dose BID after 1 week; max 3.4 mg/kg/day.
- Renal adjustment
- No adjustment required (hepatically metabolized).
- Hepatic adjustment
- Start at low dose; titrate slowly. Significantly reduced clearance in severe hepatic impairment. Monitor for excessive bradycardia and hypotension.
- Geriatric
- Start 10 mg BID; titrate slowly. Increased sensitivity to beta-blockade. Monitor for bradycardia, hypotension, confusion.
- Max dose
- 640 mg/day (hypertension); 320 mg/day (tremor); 60 mg/day (pediatric arrhythmia)
Pharmacokinetics
Onset
Oral: 30-60 minutes. Peak antihypertensive effect: 1-1.5 hours.
Peak effect
Oral: peak plasma at 1-4 hours. ER: 6 hours.
Duration
IR: 6-8 hours (supports BID-TID dosing). ER: 24 hours.
Half-life
3-6 hours (IR); 8-10 hours (ER). Highly lipophilic with extensive tissue distribution.
Bioavailability
~25-30% (oral; extensive first-pass hepatic metabolism).
Protein binding
~90% (bound to albumin and alpha-1-acid glycoprotein).
Metabolism
Extensive hepatic via CYP1A2 (primary — ring hydroxylation, O-dealkylation), CYP2D6, and CYP2C19. Multiple active and inactive metabolites.
Excretion
Renal: ~96-99% (as metabolites, primarily glucuronide conjugates). <1% excreted unchanged.
Contraindications
- Hypersensitivity to propranolol
- Severe bradycardia, heart block (2nd/3rd degree without pacemaker)
- Cardiogenic shock
- Severe hypotension
- Sick sinus syndrome
- Bronchial asthma / reactive airway disease (non-selective β-blockade — FDA contraindication)
- Relative: diabetes mellitus (masks hypoglycemia symptoms — tachycardia, tremors)
- Relative: peripheral vascular disease, Raynaud phenomenon
Side effects
Common
Fatigue, weaknessBradycardiaCold extremities (peripheral vasoconstriction)Sleep disturbances, vivid dreams, insomniaDizzinessNausea, diarrhea or constipationErectile dysfunctionDepression (CNS penetration)Bronchospasm (in asthmatics)
Serious
- Severe bradycardia, heart block, asystole
- Bronchospasm / status asthmaticus (in susceptible patients)
- Heart failure decompensation
- Severe hypotension, syncope
- Rebound hypertension/tachycardia/angina on abrupt withdrawal (upregulation of beta-receptors)
- Hypoglycemia unawareness (in diabetics — masks warning symptoms)
- Severe peripheral ischemia (Raynaud, claudication)
- Depression, suicidal ideation (rare)
- Hepatotoxicity (rare)
Pregnancy & lactation
Pregnancy
FDA PLLR: Crosses placenta. Can cause fetal bradycardia, hypoglycemia, growth restriction. Use lowest effective dose. Monitor fetal heart rate if used near delivery.
Lactation
Excreted in breast milk. May cause infant bradycardia, hypoglycemia, and respiratory distress. Use lowest effective dose. Monitor infant. AAP considers effects unknown but of concern.
Drug interactions
Amiloride
Severe
Textbook
Hyperkalaemia more likely.
Source: KDT 7e
Digitalis
Severe
Textbook
Additive depression of sinus node and A-V conduction; cardiac arrest can occur.
Avoid combination or use with extreme caution and constant monitoring.
Source: KDT 7e
Sofosbuvir
Severe
Textbook
Severe bradycardia.
Extreme caution advised if amiodarone is co-administered with sofosbuvir and a beta blocker.
Source: Harrison 22e · unknown
Aminophylline
Severe
Database
Drug interaction classified as: antagonism
Source: DDInter
Arbutamine
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Arformoterol
Severe
Database
Drug interaction classified as: antagonism
Source: DDInter
Atazanavir
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Ceritinib
Severe
Database
Drug interaction classified as: synergy
Source: DDInter
Clonidine
Severe
Database
Beta-blockers potentiate clonidine rebound hypertension on withdrawal. If clonidine stopped while on propranolol, severe rebound hypertension can occur. Additionally, both lower heart rate additively.
Taper clonidine gradually over 2-4 days if discontinuing. Do NOT stop clonidine abruptly while on beta-blocker. Monitor BP and HR closely during transition.
Source: Kimi deep-research + Cla
Diltiazem
Severe
Database
Increased propensity for AV block, severe bradycardia, and decreased left ventricular function.
Avoid concurrent administration. The concurrent administration of diltiazem with a beta blocker is contraindicated.
Source: DDInter
Disopyramide
Severe
Database
Clinical effect not specified
Source: DDInter
Related guidelines
Other Beta Blocker drugs
Ask House about Propranolol
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Sources: KD Tripathi 7e, Goodman & Gilman 14e, BNF·Verified: 2026-05-18 · House clinical team·Cockpit curated: 2026-05-18