PROPRANOLOL

CLASSIFICATION(S):

Therapeutic : antianginals, antiarrhythmics (Class II), antihypertensives,

vascular headache suppressants
Pharmacologic : beta blockers

INDICATIONS

 Management of hypertension
 Management of angina pectoris
 Management of arrhythmias
 Prevention and management of MI
 Also used to:
o Prevent vascular headaches
o Manage thyrotoxicosis
o Manage pheochromocytoma
o Treat essential tremors
o Manage hypertrophic cardiomyopathy.
 Unlabelled Uses:
o Also used to manage:
o Alcohol withdrawal
o Aggressive behavior
o Antipsychotic-associated akathisia
o Situational anxiety
o Esophageal varices.
ACTION

 Blocks stimulation of beta 1 (myocardial) and beta 2 (pulmonary, vascular, and

uterine)-adrenergic receptor sites.
 Therapeutic Effects:
o Decreased heart rate and blood pressure
o Suppression of arrhythmias
o Prevention of MI.

PHARMACOKINETICS

Absorption : Well absorbed but undergoes extensive first-pass hepatic metabolism.

Distribution : Moderate CNS penetration. Crosses the placenta; enters breast milk.
Protein Binding : 93%.
Metabolism and Excretion: Almost completely metabolized by the liver.
Half-life : 3.4–6 hr.

CONTRAINDICATIONS AND PRECAUTIONS

Contraindicated in:

 Uncompensated CHF
 Pulmonary edema
 Cardiogenic shock
 Bradycardia or heart block.

Use Cautiously in:

 Renal impairment
 Hepatic impairment
 Geriatric patients (increased sensitivity to beta blockers; initial dosage reduction
recommended)
 Pulmonary disease (including asthma)
 Diabetes mellitus (may mask signs of hypoglycemia)
 Thyrotoxicosis (may mask symptoms)
 Patients with a history of severe allergic reactions (intensity of reactions may be
increased)
 Children (increased risk of hypoglycemia, especially during fasting, such as
preoperatively, during prolonged exertion, or coexisting renal insufficiency)
 Pregnancy, lactation, or children (safety not established; all agents cross the placenta
and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory
depression).

ADVERSE REACTIONS AND SIDE EFFECTS

CNS : fatigue , weakness , anxiety, dizziness, drowsiness, insomnia, memory loss,
mental depression, mental status changes, nervousness, nightmares.
EENT : blurred vision, dry eyes, nasal stuffiness.
Resp : bronchospasm, wheezing.
CV : ARRHYTHMIAS , BRADYCARDIA , CHF , PULMONARY EDEMA ,
orthostatic hypotension, peripheral vasoconstriction.
GI : constipation, diarrhea, nausea.
GU : impotence , decreased libido.
Derm : itching, rashes.
Endo : hyperglycemia, hypoglycemia (increased in children).
MS : arthralgia, back pain, muscle cramps.
Neuro : paresthesia.
Misc : drug-induced lupus syndrome.

INTERACTIONS

Drug–Drug:

 General anesthesia, IV , phenytoin , and verapamil may cause additive myocardial

depression
 Additive bradycardia may occur with digoxin
 Additive hypotension may occur with other antihypertensives , acute ingestion of
alcohol , or nitrates
 Concurrent use with amphetamines , cocaine , ephedrine , epinephrine ,
norepinephrine , phenylephrine , or pseudoephedrine may result in unopposed
alpha-adrenergic stimulation (excessive hypertension, bradycardia)
 Concurrent thyroid administration may decrease effectiveness
 May alter the effectiveness of insulin or oral hypoglycemic agents (dosage
adjustments may be necessary)
 May decrease the effectiveness of beta-adrenergic bronchodilators and
theophylline
 May decrease the beneficial beta cardiovascular effects of dopamine or dobutamine
 Use cautiously within 14 days of MAO inhibitor therapy (may result in
hypertension)
 Cimetidine may increase blood levels and toxicity
 Concurrent NSAIDs may decrease antihypertensive action
 Smoking increases metabolism and decreases effects; smoking cessation may
increase effects.

ROUTE AND DOSAGE

 PO (Adults): Antianginal —80–320 mg/day in 2–4 divided doses or once daily as

extended/sustained-release capsules. Antihypertensive —40 mg twice daily initially;
may be increased as needed (usual range 120–240 mg/day; doses up to 1 g/day have
been used); or 80 mg once daily as extended/sustained-release capsules, increased as
needed up to 120 mg. InnoPran XL dosing form is designed to be given once daily at
bedtime. Antiarrhythmic —10–30 mg 3–4 times daily. Prevention of MI —180–240
mg/day in divided doses. Hypertrophic cardiomyopathy —20–40 mg 3–4 times daily.
Adjunct therapy of pheochromocytoma —20 mg 3 times daily to 40 mg 3–4 times
daily concurrently with alpha-blocking therapy, started 3 days before surgery is
planned. Vascular headache prevention —20 mg 4 times daily or 80 mg/day as
 extended/sustained-release capsules; may be increased as needed up to 240 mg/day.
Management of tremor —40 mg twice daily; may be increased up to 120 mg/day (up
to 320 mg have been used).
 PO (Children): Antihypertensive/antiarrhythmic —0.5–1 mg/kg/day in 2–4 divided
doses; may be increased as needed (usual range for maintenance dose is 2–4
mg/kg/day in 2 divided doses).
 IV (Adults): Antiarrhythmic —1–3 mg; may be repeated after 2 min and again in 4 hr
if needed.
 IV (Children): Antiarrhythmic —10–100 mcg (0.01–0.1 mg)/kg (up to 1 mg/dose);
may be repeated q 6–8 hr if needed.

AVAILABILITY

 Oral solution : 4 mg/ml Rx , 8 mg/ml Rx , 80 mg/ml Rx

 Tablets : 10 mg Rx , 20 mg Rx , 40 mg Rx , 60 mg Rx , 90 mg Rx , 120 mg Rx
 Sustained-release capsules: 60 mg Rx , 80 mg Rx , 120 mg Rx , 160 mg Rx
 Extended-release capsules: 60 mg Rx , 80 mg Rx , 120 mg Rx , 160 mg Rx
 Injection : 1 mg/ml Rx
 In combination with: hydrochlorothiazide (Inderide Rx , Inderide LA Rx )
 .

TIME/ACTION PROFILE (cardiovascular effects)

ONSET PEAK DURATION

PO 30 MIN 60-90 MIN 6-12 HR
PO-ER UNKNOWN 6 HR 24 HR
IV IMMEDIATE 1 MIN 4-6 HR

NURSING IMPLICATIONS

ASSESSMENT

 General: Monitor blood pressure and pulse frequently during dose adjustment period
and periodically during therapy. Assess for orthostatic hypotension when assisting
patient up from supine position.
o Patients receiving propranolol IV must have continuous ECG monitoring and
may have pulmonary capillary wedge pressure (PCWP) or central venous
pressure (CVP) monitoring during and for several hours after administration.
 Monitor intake and output ratios and daily weight. Assess patient routinely for
evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight
gain, jugular venous distention).
 Angina: Assess frequency and characteristics of anginal attacks periodically during
therapy.
 Vascular Headache Prophylaxis: Assess frequency, severity, characteristics, and
location of vascular headaches periodically during therapy.
 Lab Test Considerations: May cause ↑ BUN, serum lipoprotein, potassium,
triglyceride, and uric acid levels.
o May cause ↑ ANA titers.
 o May cause ↓ or ↑ in blood glucose levels. In labile diabetic patients,
hypoglycemia may be accompanied by precipitous ↑ of blood pressure.
 Toxicity and Overdose: Monitor patients receiving beta blockers for signs of
overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea,
bluish fingernails or palms, seizures). Notify physician or other health care
professional immediately if these signs occur.
o Hypotension may be treated with modified Trendelenburg position and IV
fluids unless contraindicated. Vasopressors (epinephrine, norepinephrine,
dopamine, dobutamine) may also be used. Hypotension does not respond to
beta agonists.
o Glucagon has been used to treat bradycardia and hypotension.

POTENTIAL NURSING DIAGNOSES

 Cardiac output, decreased (Side Effects).

 Noncompliance (Patient/Family Teaching).

IMPLEMENTATION

 High Alert : IV vasoactive medications are inherently dangerous. Oral and parenteral
doses of propranolol are not interchangeable; IV dose is 1/10 the oral dose. Patient
harm or fatalities have occurred when switching from oral to IV route. Before
administering intravenously, have second practitioner independently check original
order, dosage calculations, and infusion pump settings. Do not confuse propranolol
with pravachol. Do not confuse Inderal (propranolol) with Adderall
(amphetamine/dextroamphetamine).
 PO: Take apical pulse prior to administering. If <50 bpm or if arrhythmia occurs,
withhold medication and notify physician or other health care professional.
o Administer with meals or directly after eating to enhance absorption.
o Extended-release capsules should be swallowed whole; do not crush, open, or
chew. Propranolol tablets may be crushed and mixed with food.
o Mix propranolol oral solution with liquid or semisolid food (water, juices,
soda, applesauce, puddings). Make sure entire dose is taken. Rinse glass with
more liquid to ensure all medication is taken. Do not store after mixing.
 Direct IV: Administer undiluted or dilute each 1 mg in 10 ml of D5W for injection.
 Rate: Administer over at least 1 min.
 Intermittent Infusion: May also be diluted for infusion in 50 ml of 0.9% NaCl,
D5W, D5/0.45% NaCl, D5/0.9% NaCl, or lactated Ringer’s injection.
 Rate: Infuse over 10–15 min.

PATIENT/FAMILY TEACHING

 General: Instruct patient to take medication as directed, at the same time each day,
even if feeling well; do not skip or double up on missed doses. Take missed doses as
soon as possible up to 4 hr before next dose (8 hr with extended-release propranolol).
Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or
myocardial ischemia.
 Advise patient to make sure enough medication is available for weekends, holidays,
and vacations. A written prescription may be kept in wallet in case of emergency.
 Teach patient and family how to check pulse daily and blood pressure biweekly.
Advise patient to hold dose and contact health care professional if pulse is <50 bpm or
blood pressure changes significantly.
 May cause drowsiness or dizziness. Caution patients to avoid driving or other
activities that require alertness until response to the drug is known.
 Advise patients to change positions slowly to minimize orthostatic hypotension,
especially during initiation of therapy or when dose is increased.
 Caution patient that this medication may increase sensitivity to cold.
 Instruct patient to consult health care professional before taking any OTC medications
or herbal products, especially cold preparations, concurrently with this medication.
 Diabetic patients should closely monitor blood glucose, especially if weakness,
malaise, irritability, or fatigue occurs. May mask tachycardia and increased blood
pressure as signs of hypoglycemia, but dizziness and sweating may still occur.
 Advise patient to notify health care professional if slow pulse, difficulty breathing,
wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression,
rash, fever, sore throat, unusual bleeding, or bruising occurs.
 Instruct patient to inform health care professional of medication regimen prior to
treatment or surgery.
 Advise patient to carry identification describing disease process and medication
regimen at all times.
 Hypertension: Reinforce the need to continue additional therapies for hypertension
(weight loss, sodium restriction, stress reduction, regular exercise, moderation of
alcohol consumption, and smoking cessation). Medication controls but does not cure
hypertension.
 Angina: Caution patient to avoid overexertion with decrease in chest pain.
 Vascular Headache Prophylaxis: Caution patient that sharing this medication may
be dangerous.