Non-selective beta blocker
ATC code: C07AA05 (Propranolol)
Brand names
Inderal, Inderal LA, InnoPran XL, Hemangeol
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.
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.
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.
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.
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.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Propranolol is not chosen as first-line therapy for essential hypertension. 2024 and NG136 place beta-blockers in the fourth line after ACE inhibitors/ARBs, CCBs, and thiazide diuretics. Propranolol specifically loses to cardioselective bisoprolol and metoprolol on the side-effect profile and on the ASCOT-BPLA outcome data (Lancet 2005). Used only when other indications are present (migraine, thyrotoxicosis, tremor).
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.
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).
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.
Mechanism
Non-dihydropyridine calcium channel blocker (verapamil) + non-selective beta-blocker (propranolol) – marked additive bradycardia, AV block, negative inotropic effect. Symptomatic AV block and asystole have been reported.
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 verapamil) or verapamil with propranolol withdrawn. In heart failure, use a selective beta-blocker (bisoprolol) or carvedilol.
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.
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, ). If the combination is unavoidable, teach the patient to recognise hypoglycaemia via sweating.
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.
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FDA category C. In pregnancy, propranolol is used for thyrotoxicosis, tachycardia in hypertrophic cardiomyopathy, and severe migraine. Newborns of mothers on beta-blockers in the third trimester may have symptomatic bradycardia, hypoglycemia, and reduced birth weight. The decision is shared with the obstetrician and the relevant specialist.
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.
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.
FDA category C. FDA category C. In pregnancy, propranolol is used for thyrotoxicosis, tachycardia in hypertrophic cardiomyopathy, and severe migraine. Newborns of mothers on beta-blockers in the third trimester may have symptomatic bradycardia, hypoglycemia, and reduced birth weight. The decision is shared with the obstetrician and the relevant specialist.
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.