Propranolol (Propranolol hydrochloride)
Also sold as: Ciplar, Inderal, Propranolol LA, Betacap
Pregnancy
Cat C
Lactation
Caution
Schedule
H
Forms
Tablet (10mg, 20mg, 40mg, 80mg) +2
Indications
- Migraine prophylaxis
- Hypertension
- Angina pectoris
- Essential tremor
- Hyperthyroidism / thyroid storm (adjunctive)
- Performance anxiety
- Portal hypertension and prevention of variceal bleeding
- Hypertrophic obstructive cardiomyopathy (HOCM)
- Post-myocardial infarction (secondary prevention)
Adult Dosing
Migraine prophylaxis
40 mg twice daily initially
Increase to 80–160 mg/day in divided doses (twice daily); LA formulation once daily
Effective prophylaxis typically requires 4–8 weeks. Reassess at 6 months.
Hypertension
80 mg twice daily initially
Maintenance 80–160 mg twice daily
LA formulation preferred for once-daily compliance.
Angina
80–320 mg/day
Divided in 2–3 doses or as LA once daily
Essential tremor
40 mg twice daily to three times daily
Titrate to response (maximum 320 mg/day)
Hyperthyroidism / thyroid storm
40–80 mg four times daily
Until euthyroid state achieved; then taper
Controls adrenergic symptoms (tachycardia, tremor, sweating) but does not affect thyroid hormone synthesis.
Performance anxiety
10–40 mg once, 1 hour before the event
As needed only; not for regular use
Off-label. Very effective for situational anxiety (exams, public speaking). Test the dose before the important event.
Portal hypertension (variceal bleeding prevention)
20–80 mg twice daily
Titrate to reduce resting heart rate by 25% or to 55–60 bpm
Pediatric Dosing
Monitor heart rate and blood pressure closely. Use IR formulation.
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| Mild-moderate impairment | No dose adjustment required |
| Severe impairment | Use with caution; metabolites may accumulate |
Hepatic Adjustment
Significant first-pass metabolism. Severe hepatic impairment: markedly increased bioavailability — reduce dose substantially and titrate carefully.
Pregnancy & Lactation
Pregnancy: Category C
Associated with foetal growth restriction, neonatal bradycardia, hypoglycaemia, and respiratory depression. If used during pregnancy, monitor neonate for 48–72 hours post-delivery.
Lactation: Caution
Excreted in breast milk. Monitor infant for bradycardia and hypoglycaemia. Generally considered low risk at low doses.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Verapamil / diltiazem (non-dihydropyridine calcium channel blockers) | Additive AV nodal blockade — risk of severe bradycardia, heart block, and cardiac arrest | Major |
| Clonidine | Abrupt clonidine withdrawal causes rebound hypertension, worsened by beta-blockade masking reflex tachycardia | Major |
| Antidiabetics (insulin, sulfonylureas) | Masks tachycardia (key symptom of hypoglycaemia); may prolong hypoglycaemic episodes | Moderate |
| Sympathomimetics (adrenaline/epinephrine) | Unopposed alpha-adrenergic stimulation causes severe hypertension with reflex bradycardia | Moderate |
| NSAIDs (ibuprofen, diclofenac) | Reduce antihypertensive efficacy of propranolol via prostaglandin inhibition | Moderate |
| Rizatriptan | Propranolol increases rizatriptan AUC by 70% — use rizatriptan 5 mg dose only | Major |
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Side Effects
Common
- Fatigue, lethargy
- Bradycardia
- Cold extremities
- Sleep disturbance, nightmares (lipophilic — CNS penetration)
- Depression (rare)
- Bronchospasm (in susceptible individuals)
- Erectile dysfunction
Serious / Discontinue If
- Severe bradycardia or heart block
- Bronchospasm (potentially life-threatening in asthma/COPD)
- Acute heart failure exacerbation
- Rebound angina or MI on abrupt withdrawal
- Masking of hypoglycaemia in diabetics
Contraindications
- Asthma or severe COPD with bronchospasm
- Cardiogenic shock
- Sick sinus syndrome, significant AV block (without pacemaker)
- Uncontrolled heart failure
- Severe peripheral vascular disease (critical limb ischaemia)
- Abrupt discontinuation (must taper over at least 2 weeks)
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Ciplar 10mg | Cipla | ₹12/10 tab |
| Inderal 10mg | AstraZeneca | ₹22/10 tab |
| Betacap TR 40mg | Sun Pharma | ₹28/10 cap |
Monitoring Required
- Resting heart rate (target 55–65 bpm for migraine/portal hypertension prophylaxis)
- Blood pressure
- Blood glucose in diabetic patients (masked hypoglycaemia risk)
- Lung function if history of respiratory disease
- Lipid profile (long-term use may worsen triglycerides)
Patient Counseling Points
- NEVER stop this medicine suddenly — abrupt withdrawal can cause rebound angina or even a heart attack; taper over 2 weeks under medical supervision
- Take at the same time(s) each day
- If you are diabetic, be aware that propranolol can hide the fast heartbeat that warns you of low blood sugar
- Tell your doctor if you have asthma or breathing problems before starting
- You may feel tired or have cold hands and feet — this usually improves over time
- Avoid alcohol as it can lower blood pressure further
- For migraine prevention, this medicine takes 4–8 weeks to work — do not stop early
- If you take rizatriptan for migraine attacks, always use the 5 mg dose
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Clinically reviewed by: Dr. Priya Nair, DM Neurology, DM Neurology, Senior Consultant Neurologist
Last reviewed: 2026-04-01
References
- Linde M, et al. Propranolol for migraine prophylaxis. Cochrane Database Syst Rev. 2004.
- Propranolol prescribing information — Cipla India.
- JNC 8 Guidelines for hypertension management.