Formulary
Propranolol hydrochloride: Indications, Dosing, Side Effects and Interactions
Propranolol hydrochloride clinical drug profile including indications, dosing, side effects, cautions and interactions.
MedNext Academy | 10 min read
Propranolol hydrochloride: Indications, Dosing, Side Effects and Interactions
Propranolol hydrochloride clinical drug profile including indications, dosing, side effects, cautions and interactions.
Indications and dose
**Thyrotoxicosis (adjunct)**
- **Adult** (By Mouth): 10-40 mg 3-4 times a day.
**Thyrotoxic crisis**
- **Adult** (By Intravenous Injection): 1 mg, to be given over 1 minute, dose may be repeated if necessary at intervals of 2 minutes, maximum total dose is 5 mg in anaesthesia; maximum 10 mg per course.
**Hypertension**
- **Adult** (By Mouth): Initially 80 mg twice daily, dose should be increased at weekly intervals as required; maintenance 160-320 mg daily.
**Prevention of bleeding from medium or large oesophageal varices [in patients with cirrhosis]**
- **Adult** (By Mouth): 40 mg twice daily, increased if necessary up to 160 mg twice daily, dose to be adjusted gradually according to heart rate and blood pressure.
**Primary prevention of decompensated cirrhosis [in patients with clinically significant portal hypertension]**
- **Adult** (By Mouth): 40 mg twice daily, dose to be adjusted gradually according to heart rate and blood pressure.
**Phaeochromocytoma (only with an alpha-blocker) in preparation**
- **Adult** (By Mouth): for surgery 60 mg daily for 3 days before surgery.
**Phaeochromocytoma (only with an alpha-blocker) in patients unsuitable**
- **Adult** (By Mouth): for surgery 30 mg daily.
**Angina**
- **Adult** (By Mouth): Initially 40 mg 2-3 times a day; maintenance 120-240 mg daily.
**Hypertrophic cardiomyopathy,Anxiety tachycardia**
- **Adult** (By Mouth): 10-40 mg 3-4 times a day.
**Anxiety with symptoms such as palpitation, sweating and tremor**
- **Adult** (By Mouth): 40 mg once daily, then increased if necessary to 40 mg 3 times a day.
**Prophylaxis after myocardial infarction**
- **Adult** (By Mouth): Initially 40 mg 4 times a day for 2-3 days, then 80 mg twice daily, start treatment 5 to 21 days after infarction.
**Essential tremor**
- **Adult** (By Mouth): Initially 40 mg 2-3 times a day; maintenance 80-160 mg daily.
**Migraine prophylaxis**
- **Adult** (By Mouth): 80-240 mg daily in divided doses.
**Arrhythmias**
- **Adult** (By Mouth): 10-40 mg 3-4 times a day.
- **Adult** (By Intravenous Injection): 1 mg, to be given over 1 minute, dose may be repeated if necessary at intervals of 2 minutes, maximum 10 mg per course (5 mg in anaesthesia).
**Hyperthyroidism with autonomic symptoms for propranolol hydrochloride**
- **Neonate** (By mouth): Initially 250-500 micrograms/kg every 6-8 hours, adjusted according to response.
- **Child** (By mouth): Initially 250-500 micrograms/kg every 8 hours, adjusted according to response; increased if necessary up to 1 mg/kg every 8 hours (max. per dose 40 mg every 8 hours).
- **Neonate** (By intravenous injection): Initially 20-50 micrograms/kg every 6-8 hours, adjusted according to response, to be given over 10 minutes.
- **Child** (By intravenous injection): Initially 25-50 micrograms/kg every 6-8 hours (max. per dose 5 mg), adjusted according to response, to be given over 10 minutes.
**Thyrotoxicosis (adjunct) for propranolol hydrochloride**
- **Neonate** (By mouth): Initially 250-500 micrograms/kg every 6-8 hours, adjusted according to response.
- **Child** (By mouth): Initially 250-500 micrograms/kg every 8 hours, adjusted according to response; increased if necessary up to 1 mg/kg every 8 hours (max. per dose 40 mg every 8 hours).
- **Neonate** (By intravenous injection): Initially 20-50 micrograms/kg every 6-8 hours, adjusted according to response, to be given over 10 minutes.
- **Child** (By intravenous injection): Initially 25-50 micrograms/kg every 6-8 hours (max. per dose 5 mg), adjusted according to response, to be given over 10 minutes.
**Thyrotoxic crisis for propranolol hydrochloride**
- **Neonate** (By mouth): Initially 250-500 micrograms/kg every 6-8 hours, adjusted according to response.
- **Child** (By mouth): Initially 250-500 micrograms/kg every 8 hours, adjusted according to response; increased if necessary up to 1 mg/kg every 8 hours (max. per dose 40 mg every 8 hours).
- **Neonate** (By intravenous injection): Initially 20-50 micrograms/kg every 6-8 hours, adjusted according to response, to be given over 10 minutes.
- **Child** (By intravenous injection): Initially 25-50 micrograms/kg every 6-8 hours (max. per dose 5 mg), adjusted according to response, to be given over 10 minutes.
**Hypertension for propranolol hydrochloride**
- **Neonate** (By mouth): Initially 250 micrograms/kg 3 times a day, then increased if necessary up to 2 mg/kg 3 times a day.
- **Child 1 month-11 years** (By mouth): Initially 0.25-1 mg/kg 3 times a day, then increased to 5 mg/kg daily in divided doses, dose should be increased at weekly intervals.
- **Child 12-17 years** (By mouth): Initially 80 mg twice daily, then increased if necessary up to 160-320 mg daily, dose should be increased at weekly intervals, slow-release preparations may be used for once daily administration.
**Prevention of bleeding from medium or large oesophageal varices [in patients with cirrhosis] for propranolol hydrochloride**
- **Child 16-17 years** (By mouth): 40 mg twice daily, increased if necessary up to 160 mg twice daily, dose to be adjusted gradually according to heart rate and blood pressure.
**Primary prevention of decompensated cirrhosis [in patients with clinically significant portal hypertension] for propranolol hydrochloride**
- **Child 16-17 years** (By mouth): 40 mg twice daily, dose to be adjusted gradually according to heart rate and blood pressure.
**Migraine prophylaxis for propranolol hydrochloride**
- **Child 2-11 years** (By mouth): Initially 200-500 micrograms/kg twice daily; usual dose 10-20 mg twice daily (max. per dose 2 mg/kg twice daily).
- **Child 12-17 years** (By mouth): Initially 20-40 mg twice daily; usual dose 40-80 mg twice daily (max. per dose 120 mg); maximum 4 mg/kg per day.
**Arrhythmias for propranolol hydrochloride**
- **Neonate** (By mouth): 250-500 micrograms/kg 3 times a day, adjusted according to response.
- **Child** (By mouth): 250-500 micrograms/kg 3-4 times a day (max. per dose 1 mg/kg 4 times a day), adjusted according to response; maximum 160 mg per day.
- **Neonate** (By slow intravenous injection): 20-50 micrograms/kg, then 20-50 micrograms/kg every 6-8 hours if required, eCG monitoring required.
- **Child** (By slow intravenous injection): 25-50 micrograms/kg, then 25-50 micrograms/kg every 6-8 hours if required, eCG monitoring required.
**Tetralogy of Fallot for propranolol hydrochloride**
- **Neonate** (By mouth): 0.25-1 mg/kg 2-3 times a day (max. per dose 2 mg/kg 3 times a day).
- **Child 1 month-11 years** (By mouth): 0.25-1 mg/kg 3-4 times a day, maximum dose to be given in divided doses; maximum 5 mg/kg per day.
- **Neonate** (By slow intravenous injection): Initially 15-20 micrograms/kg (max. per dose 100 micrograms/kg), then 15-20 micrograms/kg every 12 hours if required, eCG monitoring is required with administration.
- **Child 1 month-11 years** (By slow intravenous injection): Initially 15-20 micrograms/kg (max. per dose 100 micrograms/kg), higher doses are rarely necessary, then 15-20 micrograms/kg every 6-8 hours if required, eCG monitoring is required with administration.
**Infantile haemangioma [proliferating, with ulceration, risk of disfigurement, or functional impairment] (initiated under specialist supervision) for propranolol hydrochloride**
- **Child** (By mouth): Initially 1 mg/kg daily in 3 divided doses, to be increased after at least 24 hours, usual maintenance 2 mg/kg daily in 2-3 divided doses, dosing to be given using 5mg/5mL oral solution. Review treatment after 2-3 months and adjust dosing for weight gain. Most patients do not need treatment beyond 17 months of age, for neonates, preterm infants, patients with comorbidities, or those with segmental infantile haemangioma and suspected PHACES syndrome, reduced dosing is required, as determined by the supervising specialist; maximum 3 mg/kg per day.
Cautions
For all beta-adrenoceptor blockers (systemic) Diabetes; first-degree AV block; history of obstructive airways disease (introduce cautiously); myasthenia gravis; portal hypertension (risk of deterioration in liver function); psoriasis; symptoms of hypoglycaemia may be masked; symptoms of thyrotoxicosis may be masked Cautions, further information Elderly Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information). Potentially inappropriate: in combination with verapamil or diltiazem (risk of heart block) with bradycardia (heart rate less than 50 beats per minute), or second- or third-degree AV block (contra-indicated; risk of complete heart block, asystole) in diabetes mellitus patients with frequent hypoglycaemic episodes (risk of suppressing hypoglycaemic symptoms) if prescribed a non-selective beta-blocker (including topical beta-blockers) in a history of asthma requiring treatment (contra-indicated in asthma; risk of increased bronchospasm)
Contraindications
For all beta-adrenoceptor blockers (systemic) Asthma; cardiogenic shock; hypotension; marked bradycardia; metabolic acidosis; phaeochromocytoma (apart from specific use with alpha-blockers); Prinzmetal's angina; second-degree AV block; severe peripheral arterial disease; sick sinus syndrome; third-degree AV block; uncontrolled heart failure Contra-indications, further information Bronchospasm Beta-blockers, including those considered to be cardioselective, should usually be avoided in patients with a history of asthma, bronchospasm or a history of obstructive airways disease. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution and under specialist supervision. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken.
Side effects
For all beta-adrenoceptor blockers (systemic) Common or very common Abdominal discomfort; bradycardia; confusion; depression; diarrhoea; dizziness; dry eye (reversible on discontinuation); dyspnoea; erectile dysfunction; fatigue; headache; heart failure; nausea; paraesthesia; peripheral coldness; rash (reversible on discontinuation); Raynaud's phenomenon; sleep disorders; syncope; visual impairment; vomiting Uncommon Alopecia; atrioventricular block; bronchospasm Rare or very rare Hallucination; psoriasis exacerbated Side-effects, further information With administration by intravenous injection, excessive bradycardia can occur and may be countered with intravenous injection of atropine sulfate. Overdose Therapeutic overdosages with beta-blockers may cause lightheadedness, dizziness, and possibly syncope as a result of bradycardia and hypotension; heart failure may be precipitated or exacerbated. With administration by intravenous injection, excessive bradycardia can occur and may be countered with intravenous injection of atropine sulfate. For details on the management of poisoning, see Beta-blockers, under Emergency treatment of poisoning . Side-effects For propranolol hydrochloride Rare or very rare Intermittent claudication; memory loss; mood altered; neuromuscular dysfunction; postural hypotension; psychosis; skin reactions; thrombocytopenia Frequency not known Hypoglycaemia Overdose Severe overdosages with propranolol may cause cardiovascular collapse, CNS depression, and convulsions.
Interactions
**Other interactions (25):**
- Care should be taken when prescribing beta-adrenoceptor blocking drugs with Class I anti-arrhythmic drugs (e.g.
- Digitalis glycosides, in association with beta-blockers could increase the atrio-ventricular conduction time.
- Beta-adrenoceptor blocking drugs should be used with caution in combination with calcium channel blockers such as verapamil or diltiazem in patients with impaired ventricular function and /or...
- Beta-blockers or calcium channel blockers should not be given intravenously within 48 hours of discontinuing either one or the other.
- Use with nifedipine or other dihydropyridines may cause an increased risk of hypotension, and heart failure may occur in patients with undiscovered cardiac insufficiency.
- Propranolol modifies the tachycardia of hypoglycaemia and care should be taken when treating diabetic patients with Bedranol* SR whether or not they are also taking hypoglycaemic agents.
Pregnancy
For all beta-adrenoceptor blockers (systemic) Beta-blockers may cause intra-uterine growth restriction, neonatal hypoglycaemia, and bradycardia; the risk is greater in severe hypertension.
Breast feeding
For all beta-adrenoceptor blockers (systemic) With systemic use in the mother, infants should be monitored as there is a risk of possible toxicity due to beta-blockade. However, the amount of most beta-blockers present in milk is too small to affect infants.
Hepatic impairment
Caution (increased risk of hepatic encephalopathy; risk of increased half-life). M When used for Prevention of bleeding from medium or large oesophageal varices or Primary prevention of decompensated cirrhosis: Caution (may have greater effect on heart rate and blood pressure). A Dose adjustments With oral use: Consider dose reduction. M
Renal impairment
Use with caution (risk of increased half-life). M Dose adjustments Consider dose reduction. M
Medicinal forms
Solution,Tablet,Capsule,Solution
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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