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Propranolol ER

Class
Adrenergic receptor blockers
Subclass
Non-cardioselective β-blockers
Generic name
Propranolol hydrochloride ER
Brand names
Inderal XL®, Inderal La®
Common formulations
Capsule
See also
Propranolol (Hemangeol®)
Dosage and administration
Adults patients
Treatment
Hypertension
•
Start at: 80 mg PO daily
•
Maintenance: 80-120 mg PO daily
•
Maximum: 120 mg per day
Dosing for XL formulation.
Hypertrophic subaortic stenosis
•
80-160 mg PO daily
Stable angina
•
Maintenance: 80-160 mg PO daily
•
Maximum: 320 mg per day
Titrate every 3 to 7 days until optimal response.
Prevention
Prevention of migraine attacks
•
Start at: 80 mg PO daily
•
Maintenance: 160-240 mg PO daily
If a satisfactory response is not obtained within four to six weeks after reaching the maximal dose, discontinue treatment.
Other off-label uses
•
Treatment of essential tremor
•
Treatment of HF
•
Treatment of hypertension
•
Treatment of paroxysmal SVT
•
Treatment of premature ventricular contractions
•
Treatment of thyrotoxicosis
•
Treatment of VT
•
Secondary prevention of ventricular arrhythmias
Indications for use
Labeled indications
Adults
•
Treatment of hypertension
•
Treatment of hypertrophic subaortic stenosis
•
Treatment of stable angina
•
Prevention of migraine attacks
Off-label indications
Adults
•
Treatment of essential tremor
•
Treatment of premature ventricular contractions
•
Treatment of thyrotoxicosis
•
Treatment of VT
•
Secondary prevention of ventricular arrhythmias
Children
•
Treatment of HF
•
Treatment of hypertension
•
Treatment of paroxysmal SVT
Safety risks
Contraindications
Acute pulmonary edema, cardiogenic shock, or decompensated acute HF, particularly in severely compromised LV dysfunction
For the treatment of hypertensive emergencies
Hypersensitivity to propranolol hydrochloride or its components
Sinus bradycardia and greater than first-degree block
Bronchial asthma or COPD
Warnings and precautions
Bradycardia
•
Use extreme caution in patients with WPW syndrome.
Cardiac failure
•
Maintain a high level of suspicion as propranolol can cause depression of myocardial contractility and may precipitate HF and cardiogenic shock.
Decreased drug efficacy
•
Use caution in patients being treated with epinephrine, as patients on beta blockers may experience a reduced response to epinephrine.
Exacerbation of Raynaud's phenomenon
•
Use caution in patients with pre-existing Raynaud's phenomenon or peripheral vascular disease.
Hypertensive crisis
•
Use extreme caution in patients with pheochromocytoma.
Mask symptoms of hypoglycemia
•
Use caution in patients with diabetes mellitus, as propranolol may mask the initial signs and symptoms of hypoglycemia.
Mask symptoms of thyrotoxicosis
•
Use caution in patients with hyperthyroidism or thyrotoxicosis.
Myocardial infarction
•
Do not discontinue abruptly, as rapid dose reduction or withdrawal may cause withdrawal effects including myocardial infarction.
Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, urticaria
•
Maintain a high level of suspicion for cutaneous reactions triggered by the use of propranolol.
Specific populations
Renal impairment
eGFR 20-50 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required. Titrate to response. Monitor renal function.
eGFR 10-20 mL/min/1.73 m²
•
Reduce starting dose. Titrate to response. Monitor renal function.
eGFR < 10 mL/min/1.73 m²
•
Reduce starting dose. Titrate to response. Monitor renal function.
Renal replacement therapy
Continuous renal replacement
•
Reduce starting dose. Dose as in eGFR 10-20 mL/min/1.73 m². Titrate to response. Monitor renal function.
Intermittent hemodialysis
•
Reduce starting dose. Dose as in eGFR < 10 mL/min/1.73 m². Titrate to response. Monitor renal function.
Peritoneal dialysis
•
Reduce starting dose. Dose as in eGFR < 10 mL/min/1.73 m². Titrate to response. Monitor renal function.
Hepatic impairment
Any severity
•
Use with caution. Titrate with caution.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if benefits outweigh potential risks. Evidence of fetal harm in humans. Monitor for fetal bradycardia. Monitor neonates for hypoglycemia and respiratory depression. Those managed for hypertension may continue treatment in pregnancy unless contraindications exists. Propranolol can be used for maternal arrhythmias in pregnancy. Use of propranolol is acceptable for treatment of thyrotoxicosis in pregnancy.
Breastfeeding
Acceptable for use during breastfeeding.
Unknown drug levels in breastfed infants.
May potentially cause adverse effects in breastfed infants.
Some adverse effects on lactation reported.
Adverse reactions
Very common > 10%
•
Bradycardia, hypotension
Common 1-10%
•
Erectile dysfunction, dizziness, fatigue, insomnia, nausea, vomiting
Uncommon < 1%
•
AV block, bronchospasm, ↓ blood glucose, ↑ blood glucose, raynaud's phenomenon, nightmares
Unknown frequency
•
Agitation, agranulocytosis, alopecia, colitis, coma, diabetes mellitus, diaphoresis, erythema multiforme, exfoliative dermatitis, heart failure, hypertension, ↑ liver enzymes, ↑ serum potassium, ↑ serum triglycerides, laryngospasm, lethargy, Peyronie's disease, pharyngitis, psoriasiform rash, abdominal pain, confusion, constipation, cough, depression, diarrhea, dyspnea, emotional lability, fever, hallucinations, headache, irritability, itching, loss of appetite, lupus-like symptoms, memory impairment, palpitations, paresthesia, seizure, somnolence, visual disturbances, weakness, sinus tachycardia, skin dryness, Stevens-Johnson syndrome, thrombotic thrombocytopenic purpura, thrombosis, toxic epidermal necrolysis, tremor, urticaria, xerophthalmia
Interactions
Drug(s)
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