Non-selective beta blocker
Brand names: Inderal, Inderal LA, InnoPran XL, Hemangeol
Updated · Methodology
First line
Propranolol reduces hand essential tremor amplitude by 50–60 percent in most patients. 2022 classifies it at level A: first-line therapy alongside primidone. Effect develops over 1–2 weeks of titration at 80–320 mg/day. In patients with borderline airway obstruction, selective β1-blockers (metoprolol) are preferred, although their efficacy in tremor is lower.
Sources
ICD-10: G25.0 · ICD-11: 8A04.10
First line
Oral propranolol is first-line systemic therapy for complicated infantile hemangiomas: function-threatening (periorbital, perinasal), ulcerated, large facial lesions. 2019 recommends starting at 5 weeks of age at 1–3 mg/kg/day in 2–3 divided doses. Treatment continues for up to 12 months. Regression efficacy exceeds 95 percent in large case series. Before the propranolol era, systemic glucocorticoids were standard with a worse side-effect profile.
Before initiation, PHACE syndrome is excluded (brain MRI in segmental facial hemangiomas): propranolol can worsen cerebral ischemia in children with vascular anomalies. Inpatient initiation is recommended in infants under 8 weeks and with comorbidities.
Sources
ICD-10: D18.0 · ICD-11: 2E81.2
First line
Propranolol reduces migraine attack frequency by at least 50 percent in half of patients at 80–240 mg/day. 2019 classifies it at level A: first-line prevention alongside topiramate, metoprolol, and timolol. Effect develops over 4–8 weeks. Preferred in patients with co-existing hypertension or anxiety; avoided in asthma, symptomatic bradycardia, and depression.
Sources
ICD-10: G43.9 · ICD-11: 8A80.Z
Adjunct
Propranolol is a non-selective beta-blocker, lowers blood pressure, and hypertension is among its registered indications. But for uncomplicated hypertension beta-blockers are not the first choice (ACE inhibitors/ARBs, dihydropyridine CCBs, and thiazide-like diuretics are preferred); beta-blockers are added for specific indications such as coronary disease, heart failure, arrhythmias, or after myocardial infarction. Propranolol itself is rarely used for primary hypertension, more often for tremor, migraine prophylaxis, and portal hypertension. Do not stop it abruptly.
Sources
ICD-10: I10 · ICD-11: BA00
First line
Propranolol controls adrenergic symptoms of thyrotoxicosis (tachycardia, tremor, anxiety) until euthyroidism is achieved with antithyroid drugs or radioactive iodine. 2016 recommends non-selective beta-blockers as the standard; propranolol additionally inhibits peripheral T4-to-T3 conversion, reinforcing the therapeutic effect. Doses 40–160 mg/day in 3–4 divided doses. Selective alternatives – metoprolol, atenolol – are used in patients with bronchial obstruction.
Sources
ICD-10: E05 · ICD-11: 5A02
Blocks β1 and β2 adrenoreceptors. Reduces heart rate, blood pressure, contractility. Used for thyrotoxicosis, essential tremor, migraine prophylaxis, infantile hemangiomas. Contraindicated in asthma due to β2 blockade.
AEMPS summary of product characteristics (section 4.6): as with all drugs, propranolol should not be given in pregnancy unless considered essential. There is no evidence of teratogenicity with propranolol. Beta-blockers reduce placental blood flow, which can cause intrauterine fetal death, immaturity and preterm delivery. Adverse effects may also occur, especially hypoglycaemia and bradycardia in the newborn and bradycardia in the fetus, and the newborn has a higher risk of cardiac and pulmonary complications after birth.
Fully compatible. Hale L2. RID 0.4%. No infant bradycardia or hypoglycemia reported at standard doses. Beta-blocker of choice in breastfeeding for maternal tachycardia, migraine, or anxiety.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
9 pairs found. Sorted from critical to minor.
Mechanism
Additive bradycardia and AV conduction suppression. Propranolol is non-selective, with higher risk than bisoprolol (affects β2 receptors, potentially causing bronchospasm in asthma).
Symptoms
Bradycardia (heart rate below 50/min), dizziness, syncope. ECG: first- to second-degree AV block. Older patients: fall risk.
Management
The combination is appropriate in cardiology. Reduce propranolol by 25–50% when starting amiodarone. Check pulse and ECG at 1 and 4 weeks. In asthma or COPD, a selective beta-blocker (bisoprolol) is preferred.
Sources
Mechanism
Propranolol is a non-selective beta-blocker (β1 and β2). On abrupt clonidine withdrawal, additional β2-blockade amplifies the residual α1 effect, making the hypertensive crisis particularly severe.
Symptoms
Abrupt clonidine withdrawal causes hypertensive crisis: sharp blood pressure rise, headache, tachycardia, anxiety, sweating. Symptoms appear 18–24 hours after a missed clonidine dose.
Management
For planned clonidine withdrawal, stop propranolol 3–7 days beforehand, then taper clonidine over 1–2 weeks. Alternative antihypertensives: an ACE-I plus amlodipine (without clonidine) or a selective beta-blocker (bisoprolol).
Sources
Mechanism
Non-dihydropyridine calcium channel blocker (diltiazem) + non-selective beta-blocker (propranolol) – marked additive bradycardia, AV block, negative inotropic effect. Risk of symptomatic AV block, especially in older patients and left ventricular dysfunction.
Symptoms
Bradycardia (heart rate below 50/min), dizziness, syncope. ECG: first- to second-degree AV block. Older patients: fall risk.
Management
Avoid the combination. For atrial fibrillation rate control, propranolol + digoxin (without diltiazem) or diltiazem with propranolol withdrawn. In heart failure, a selective beta-blocker (bisoprolol) or carvedilol is preferable.
Sources
Mechanism
Verapamil and propranolol both slow the heart rate and conduction through the atrioventricular (AV) node and reduce myocardial contractility; taken together, these effects add up (verapamil and propranolol SmPCs). With verapamil and beta-blockers, marked bradycardia, AV block up to complete heart block, heart failure and cardiovascular collapse have been reported (verapamil and propranolol labels of the US Food and Drug Administration, ). The risk is higher with impaired ventricular function and with sinoatrial or AV conduction disorders (propranolol SmPC).
Symptoms
Slow pulse, dizziness, weakness, fainting, a sharp fall in blood pressure. Shortness of breath and swelling if heart failure develops. On the electrocardiogram (ECG): high-grade atrioventricular block (verapamil and propranolol SmPCs).
Management
Avoid the combination, especially in decompensated heart failure (propranolol SmPC). Avoid verapamil in patients on a beta-blocker who have any degree of ventricular dysfunction (verapamil label of the US Food and Drug Administration, ). Intravenous verapamil is contraindicated in patients receiving an intravenous beta-blocker, and the intravenous forms of the two drugs are not given within a few hours of each other (FDA label for verapamil injection). If the patient is taking one of the drugs, stop it 48 hours before giving the other intravenously and 7 days before starting the other by mouth (propranolol SmPC). If the combination is still used for hypertension, use it only with caution and close monitoring (verapamil FDA label); if second- or third-degree atrioventricular block develops, withhold further verapamil doses (verapamil SmPC).
Sources
Mechanism
Additive bradycardia, hypotension, and sedation. Propranolol is non-selective (blocks β1 and β2); risk higher than with bisoprolol.
Symptoms
Lower blood pressure, postural dizziness, fatigue. Older patients: fall risk.
Management
In older patients, check pulse and blood pressure 1–2 weeks after start. In asthma or COPD, a selective beta-blocker (bisoprolol, metoprolol) is preferable. Alternative anxiolytic: hydroxyzine or a short lorazepam course.
Mechanism
Additive bradycardia and orthostatic hypotension. Propranolol is non-selective (blocks β1 and β2); bradycardia risk is higher than with bisoprolol. Plus additive cardiac anticholinergic effect.
Symptoms
Bradycardia (heart rate below 50/min), dizziness, syncope. In asthma or COPD: bronchospasm risk. Older patients: delirium and fall risk.
Management
In older patients, check pulse and blood pressure 1–2 weeks after starting amitriptyline. In asthma or COPD, a selective beta-blocker (bisoprolol, metoprolol) is preferable.
Sources
Mechanism
Additive bradycardia and hypotension. Propranolol is non-selective (blocks β1 and β2); risk is higher than with bisoprolol – bronchospasm possible in asthma.
Symptoms
Lower blood pressure, postural dizziness, fatigue. Older patients: fall risk.
Management
The combination is acceptable in ischaemic heart disease. In asthma or COPD, a selective beta-blocker (bisoprolol, metoprolol) is preferable. Check pulse and blood pressure 1–2 weeks after start.
Sources
Mechanism
Beta-blockers mask adrenergic hypoglycaemia symptoms (tachycardia, tremor), leaving only sweating. Severe unrecognised hypoglycaemia risk rises in sulfonylurea-treated patients, especially older patients.
Symptoms
Sweating, confusion, vision changes, loss of contact. Adrenergic symptoms (tachycardia, tremor) are suppressed — the patient misses the hypoglycaemia.
Management
Do not prescribe propranolol in diabetes. Alternatives: cardioselective beta-blockers (metoprolol, bisoprolol, nebivolol) — minimally mask hypoglycaemia. Replace glibenclamide with modern glucose-lowering agents with lower hypoglycaemia risk: gliclazide MR, metformin, SGLT-2 inhibitors (dapagliflozin, empagliflozin), GLP-1 agonists (semaglutide, liraglutide). If the combination is unavoidable, teach the patient to recognise hypoglycaemia via sweating.
Sources
Mechanism
Propranolol is non-selective, blocks bronchial β2 receptors, and antagonises theophylline's bronchodilator effect. It triggers bronchospasm in COPD or asthma.
Symptoms
Wheezing, dyspnoea, cough, asthma exacerbation. Symptoms appear within hours or days of starting propranolol.
Management
Do not prescribe propranolol in asthma or COPD. For atrial fibrillation, hypertension, or essential tremor in obstructive lung disease, alternatives: cardioselective beta-blockers (bisoprolol, metoprolol, nebivolol) at low doses under pulmonary function monitoring. For migraine prophylaxis, propranolol alternatives: topiramate or candesartan.
Sources
Verbatim lines from the interaction sections, in the language of the label
«Combinación no recomendada: La administración concomitante de betabloqueantes y bloqueantes de los canales de calcio con efectos inotrópicos negativos (por ejemplo, verapamilo, diltiazem) puede…»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: La administración de propranolol durante la infusión de lidocaína puede aumentar la concentración plasmática de lidocaína en aproximadamente un 30%. Los pacientes que ya…»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: La administración concomitante de betabloqueantes y bloqueantes de los canales de calcio con efectos inotrópicos negativos (por ejemplo, verapamilo, diltiazem) puede…»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: Amiodarona:»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: La administración concomitante de betabloqueantes y bloqueantes de los canales de calcio con efectos inotrópicos negativos (por ejemplo, verapamilo, diltiazem) puede…»AEMPS, section 4.5 · Open on CIMA
«Puede bloquear o modificar los signos y síntomas de hipoglucemia (especialmente taquicardia). En ocasiones, propranolol provoca hipoglucemia, incluso en pacientes no diabéticos, p. ej.,neonatos…»AEMPS, section 4.4 · Open on CIMA
«Drug Interactions: Caution should be exercised when administering propranolol with drugs that slow A-V nodal conduction, e.g. digitalis, lidocaine and calcium channel blockers.»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: En el caso que se administren ambos fármacos de forma concomitante, el betabloqueante deberá retirarse varios días antes de suspenderse la administración de clonidina. Si…»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Caution should be exercised when administering propranolol with drugs that slow A-V nodal conduction, e.g. digitalis, lidocaine and calcium channel blockers.»FDA, section 7 · Open on DailyMed
«Puede bloquear o modificar los signos y síntomas de hipoglucemia (especialmente taquicardia). En ocasiones, propranolol provoca hipoglucemia, incluso en pacientes no diabéticos, p. ej.,neonatos…»AEMPS, section 4.4 · Open on CIMA
«Puede bloquear o modificar los signos y síntomas de hipoglucemia (especialmente taquicardia). En ocasiones, propranolol provoca hipoglucemia, incluso en pacientes no diabéticos, p. ej.,neonatos…»AEMPS, section 4.4 · Open on CIMA
«Drug Interactions: Caution should be exercised when administering propranolol with drugs that slow A-V nodal conduction, e.g. digitalis, lidocaine and calcium channel blockers.»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: El uso concomitante de agentes simpaticomiméticos, p. ej., adrenalina, puede contrarrestar el efecto de los betabloqueantes. Se debe tener precaución en la administración…»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: Teofilina:»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Propranolol when administered with warfarin increases the concentration of warfarin. Prothrombin time, therefore, should be monitored.»FDA, section 7 · Open on DailyMed
«Drug Interactions: ACE Inhibitors»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: Antiinflamatorios no esteroideos (AINE)/AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Amiodarone is an antiarrhythmic agent with negative chronotropic properties that may be additive to those seen with β-blockers such as propranolol.»FDA, section 7 · Open on DailyMed
«Drug Interactions: Antiarrhythmics»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: Antiarrítmicos de clase I (disopiramida, quinidina):»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: Insulina y antidiabéticos orales:»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: El uso concomitante de clorpromazina con propranolol puede provocar un marcado aumento en los niveles plasmáticos de ambos fármacos, y por lo tanto aumentar sus efectos…»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Neuroleptic Drugs»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: Barbitúricos:»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: Clorpromazina:»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: The antihypertensive effects of clonidine may be antagonized by beta-blockers. Propranolol should be administered cautiously to patients withdrawing from clonidine.»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: Los antiinflamatorios de tipo AINE contrarrestan el efecto antihipertensivo de los bloqueantes beta. Se ha estudiado principalmente con la indometacina. En un estudio…»AEMPS, section 4.5 · Open on CIMA
«Combinación no recomendada: Los glucósidos digitálicos en asociación con betabloqueantes pueden aumentar el tiempo de la conducción auriculo-ventricular.»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Co-administration of propranolol and diltiazem in patients with cardiac disease has been associated with bradycardia, hypotension, high-degree heart block and heart failure.»FDA, section 7 · Open on DailyMed
«Combinación no recomendada: Antiarrítmicos de clase I (disopiramida, quinidina):»AEMPS, section 4.5 · Open on CIMA
«CONTRAINDICATIONS: 5. Patients receiving intravenous beta-adrenergic blocking drugs (e.g., propranolol). Intravenous verapamil and intravenous beta-adrenergic blocking drugs should not be…»FDA, section 4 · Open on DailyMed
«Posibilidad de que afecte a la exposición de otros medicamentos: Se recomienda precaución cuando se administre conjuntamente con medicamentos activados o metabolizados por el CYP2D6, en especial…»AEMPS, section 4.5 · Open on CIMA
«Posibles interacciones que afectan a la agomelatina: La asociación de agomelatina con estrógenos (inhibidores moderados del CYP1A2) produce que aumente varias veces la exposición a agomelatina…»AEMPS, section 4.5 · Open on CIMA
«propranolol,»AEMPS, section 4.5 · Open on CIMA
«Betabloqueantes: Propranolol»AEMPS, section 4.5 · Open on CIMA
«La administración de dosis múltiples de propranolol no alteró la farmacocinética de almotriptán. No se observaron interacciones clínicamente significativas.»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Clinical Impact: NSAIDs may diminish the antihypertensive effect of ACE inhibitors, ARBs, or beta-blockers (including propranolol). In patients who are elderly, volume-depleted…»FDA, section 7 · Open on DailyMed
«DRUG INTERACTIONS: Clinical Impact: NSAIDs may diminish the antihypertensive effect of angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or beta-blockers…»FDA, section 7 · Open on DailyMed
«Beta Blockers: There have been reports that propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating property of epinephrine.»FDA, section 7 · Open on DailyMed
«Drug Interactions: Administration of diltiazem hydrochloride tablets concomitantly with propranolol in five normal volunteers resulted in increased propranolol levels in all subjects and…»FDA, section 7 · Open on DailyMed
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Propranolol is evaluated for the following indications with varying evidence strength: Migraine prophylaxis (evidence tier A), Essential tremor (evidence tier A), Infantile hemangioma (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of Propranolol (≥ 1 in 100): Bradycardia, hypotension, Fatigue, reduced exercise tolerance, Cold extremities, Sleep disturbance, nightmares (lipophilic – crosses the blood-brain barrier), Bronchospasm in predisposed patients. See the Safety section for uncommon and serious reactions.
AEMPS summary of product characteristics (section 4.6): as with all drugs, propranolol should not be given in pregnancy unless considered essential. There is no evidence of teratogenicity with propranolol. Beta-blockers reduce placental blood flow, which can cause intrauterine fetal death, immaturity and preterm delivery. Adverse effects may also occur, especially hypoglycaemia and bradycardia in the newborn and bradycardia in the fetus, and the newborn has a higher risk of cardiac and pulmonary complications after birth.
Fully compatible. Hale L2. RID 0.4%. No infant bradycardia or hypoglycemia reported at standard doses. Beta-blocker of choice in breastfeeding for maternal tachycardia, migraine, or anxiety.
Propranolol is contraindicated in: Asthma and severe COPD (bronchospasm risk); Second- and third-degree AV block without a pacemaker; Sick sinus syndrome; Decompensated heart failure; Cardiogenic shock. Full list in the Safety section.
bronchospasm develops in patients with pre-existing airway hyperreactivity. In healthy people propranolol does not induce asthma. Cardioselective β1-blockers (metoprolol, bisoprolol) are safer in borderline obstruction.
beta-blockers remove peripheral symptoms (tachycardia, tremor) but do not treat the underlying anxiety disorder. Standard treatment is SSRIs and psychotherapy; propranolol acts as a situational drug for stage fright.
anaprilin and obzidan are trade names for the same propranolol from different manufacturers. Efficacy is identical, only price and the tablet differ.
Direct links to regulator labels. Open in a new tab.
Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Nebivolol, Sotalol