Propranolol is a medication of the beta blocker class. It is used to treat high blood pressure, some types of irregular heart rate, thyrotoxicosis, capillary hemangiomas, akathisia, performance anxiety, and essential tremors, as well as to prevent migraine headaches, and to prevent further heart problems in those with angina or previous heart attacks. It can be taken orally, rectally, or by intravenous injection. The formulation that is taken orally comes in short-acting and long-acting versions. Propranolol appears in the blood after 30 minutes and has a maximum effect between 60 and 90 minutes when taken orally.
Common side effects include nausea, abdominal pain, and constipation. It may worsen the symptoms of asthma. Propranolol may cause harmful effects for the fetus if taken during pregnancy; however, its use during breastfeeding is generally considered to be safe. It is a non-selective beta blocker which works by blocking β-adrenergic receptors.
Propranolol was patented in 1962 and approved for medical use in 1964. It is on the World Health Organization's List of Essential Medicines. Propranolol is available as a generic medication. In 2023, it was the 69th most commonly prescribed medication in the United States, with more than 9million prescriptions.
Medical uses
Propranolol is indicated for the treatment of hypertension (high blood pressure). angina pectoris, atrial fibrillation, myocardial infarction, migraine, essential tremor, hypertrophic subaortic stenosis, and pheochromocytoma (catecholamine-secreting tumors).
Propranolol is also indicated for the treatment of proliferating infantile hemangioma requiring systemic therapy.
Beta blockers were once a first-line treatment for hypertension in the United Kingdom. They were downgraded to fourth-line in 2006 because they do not perform as well as other drugs, particularly in the elderly, and there is increasing evidence that the most common beta blockers at usual doses carry an unacceptable risk of provoking type2 diabetes.
Propranolol is not recommended for the treatment of high blood pressure by the Eighth Joint National Committee (JNC 8) because a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to an angiotensin receptor blocker was noted in one study.
Anxiety and related disorders
Propranolol is occasionally used to treat performance anxiety, although evidence to support its use in any anxiety disorders is poor. Its efficacy in managing panic disorder appears similar to benzodiazepines, while carrying lower risks for addiction or abuse. Although beta blockers such as propranolol have been suggested to be beneficial in managing physical symptoms of anxiety, its efficacy in treating generalized anxiety disorder and panic disorder remain unestablished. It is thought that beta blockers do not directly treat psychological symptoms of anxiety, but can help control physical symptoms such as palpitations and tremors. This may interfere with a positive feedback loop to indirectly reduce psychological anxiety.
A 2025 systematic review and meta-analysis found widespread prescription of beta blockers, namely propranolol, for treatment of anxiety disorders, but found no evidence of a beneficial effect relative to placebo or benzodiazepines in people with social phobia or panic disorder. However, the quality of evidence, including both numbers of studies and patients as well as quality and risk of bias of those studies, was limited. Findings were similar in a previous 2016 systematic review and meta-analysis.
Other beta blockers that have been used to treat anxiety disorders besides propranolol include atenolol, betaxolol, nadolol, oxprenolol, and pindolol.
Some experimentation has been conducted in other psychiatric areas:
Post-traumatic stress disorder (PTSD) and specific phobias Aggressive behavior of patients with brain injuries Treating the excessive drinking of fluids in psychogenic polydipsia
Post-traumatic stress disorder and phobias Propranolol is being investigated as a potential treatment for PTSD. Propranolol works to inhibit the actions of norepinephrine (noradrenaline), a neurotransmitter that enhances memory consolidation. In one small study, individuals given propranolol immediately after trauma experienced fewer stress-related symptoms and lower rates of PTSD than respective control groups who did not receive the drug. Due to the fact that memories and their emotional content are reconsolidated in the hours after they are recalled or re-experienced, propranolol can also diminish the emotional impact of already formed memories; for this reason, it is also being studied in the treatment of specific phobias, such as arachnophobia, dental fear, and social phobia. It has also been found to be helpful for some individuals with misophonia.
Ethical and legal questions have been raised surrounding the use of propranolol-based medications for use as a "memory damper", including altering memory-recalled evidence during an investigation, modifying the behavioral response to past (albeit traumatic) experiences, the regulation of these drugs, and others. However, Hall and Carter have argued that many such objections are "based on wildly exaggerated and unrealistic scenarios that ignore the limited action of propranolol in affecting memory, underplay the debilitating impact that PTSD has on those who suffer from it, and fail to acknowledge the extent to which drugs like alcohol are already used for this purpose".
Other uses Essential tremor. However, evidence for use for akathisia is insufficient. Migraine and cluster headache prevention and in primary exertional headache Hyperhidrosis (excessive sweating) Infantile hemangioma Glaucoma Thyrotoxicosis by deiodinase inhibition
Propranolol and other beta blockers may be useful in the treatment of aggression and agitation in contexts like people with schizophrenia or psychosis, brain injuries, and intellectual disabilities.
Propranolol may be used to treat severe infantile hemangiomas (IHs). This treatment shows promise as being superior to corticosteroids when treating IHs. Extensive clinical case evidence and a small controlled trial support its efficacy.
Propranolol is useful in the treatment of acute cardiovascular toxicity (e.g. in overdose) caused by sympathomimetics like amphetamine, methamphetamine, cocaine, ephedrine, and pseudoephedrine, including reducing elevations in heart rate and blood pressure caused by these agents. Other beta blockers are also used. However, the controversial yet possible phenomenon of "unopposed α-stimulation" with administration of selective beta blockers to block non-selective sympathomimetics potentially makes dual alpha-1 and beta blockers like labetalol and carvedilol more favorable for such purposes than selective beta blockers like propranolol. The rate of unopposed α-stimulation with selective beta blockers has been reported to be 0.4%, whereas no cases of unopposed α-stimulation have been reported with dual alpha and beta blockers like labetalol.
Available forms Propranolol is available as propranolol hydrochloride tablets and capsules.
Contraindications
Contraindications of propranolol include cardiogenic shock, sinus bradycardia (slow heart rate; <60 beats/minute), heart block greater than first degree, bronchial asthma, overt heart failure, and known hypersensitivity to propranolol. Other contraindications include reversible airway diseases, particularly asthma or chronic obstructive pulmonary disease (COPD), sick sinus syndrome, atrioventricular block (second- or third-degree), circulatory shock, and severe hypotension (low blood pressure).
Side effects
Pregnancy and lactation Propranolol is classified as pregnancy category as Australian Drug Evaluation Committee (ADEC) category C. Beta-blocking agents in general reduce perfusion of the placenta, which may lead to adverse outcomes for the neonate, including lung or heart complications, or premature birth. The newborn may experience additional adverse effects such as low blood sugar and a slower than normal heart rate.
Propranolol is highly bound to proteins in the bloodstream and is distributed into breast milk at very low levels.[No authors listed] (2007). "Propranolol". In: Drugs and Lactation Database. U.S. National Library of Medicine Toxicology Data Network. Retrieved 25 February 2013. These low levels are not expected to pose any risk to the breastfeeding infant, and the American Academy of Pediatrics considers propranolol therapy "generally compatible with breastfeeding."
Overdose Propranolol overdose has been associated with symptoms including bradycardia and hypotension. These symptoms may be managed by drugs including glucagon, isoprenaline (isoproterenol), dopamine, phosphodiesterase inhibitors, or atropine, whereas epinephrine may provoke uncontrolled hypertension due to unopposed alpha stimulation and is not indicated. Propranolol overdose has also been associated with seizures. Cardiac arrest may occur in propranolol overdose due to sudden ventricular arrhythmias, or cardiogenic shock which may ultimately culminate in bradycardic PEA.
Interactions Pharmacodynamic interactions Since beta blockers are known to relax the cardiac muscle and constrict the smooth muscle, they have an additive effect with other drugs that decrease blood pressure or decrease cardiac contractility or conductivity. Pharmacodynamic interactions may occur with other drugs affecting the cardiovascular system, including propafenone, quinidine, amiodarone, cardiac glycosides, calcium channel blockers like verapamil and diltiazem, ACE inhibitors, alpha blockers like prazosin, catecholamine-depleting drugs like reserpine, ergot alkaloids, and adrenergic receptor agonists including epinephrine (adrenaline), isoprenaline (isoproterenol), dobutamine, β2-adrenergic receptor agonists like salbutamol, levosalbutamol, formoterol, salmeterol, and clenbuterol, and α2-adrenergic receptor agonists like clonidine. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have hypotensive side effects and these may be exacerbated by propranolol. Hypotension and cardiac arrest have been reported with the combination of propranolol and haloperidol. Nonsteroidal anti-inflammatory drugs (NSAIDs), which include drugs like ibuprofen, naproxen, and aspirin, have been reported to blunt the antihypertensive effects of beta blockers like propranolol. The NSAID indomethacin specifically may reduce the efficacy of propranolol in decreasing heart rate and blood pressure.
Effects of drugs on propranolol Propranolol is metabolized by cytochrome P450 enzymes including CYP2D6, CYP1A2, and CYP2C19. Levels of propranolol may be increased by CYP2D6 inhibitors such as amiodarone, bupropion, cimetidine, duloxetine, fluoxetine, paroxetine, propafenone, quinidine, and ritonavir, by CYP1A2 inhibitors such as imipramine, cimetidine, ciprofloxacin, fluvoxamine, isoniazid, theophylline, zileuton, zolmitriptan, and rizatriptan, and by CYP2C19 inhibitors such as fluconazole, cimetidine, fluoxetine, fluvoxamine, teniposide, and tolbutamide. No interactions with propranolol were observed with ranitidine, lansoprazole, or omeprazole. Propranolol levels may be reduced by inducers of hepatic metabolism including rifampin, alcohol, phenytoin, phenobarbital, and cigarette smoking.