page119
years.
Treatment
should be initiated by those experi-
enced in the management of heart failure (section 2.5.5).
Thyrotoxicosis
Beta-blockers are used in pre-opera-
tive preparation for
thyroidectomy.
Administration of
propranolol
can reverse clinical
symptoms of
thyro-
toxicosis
within 4 days.
Routine tests of increased thy-
roid function remain unaltered.
The thyroid gland is
rendered less vascular thus making surgery easier (sec-
tion 6.2.2).
Other uses
Beta-blockers have been used to alleviate
some symptoms
of
anxiety
;
probably patients
with
palpitation,
tremor,
and tachycardia respond best (see
also section 4.1.2 and section 4.9.3).
Beta-blockers are
also used in the
prophylaxis
of
migraine
(section
4.7.4.2). Betaxolol, carteolol, levobunolol, metipranolol,
and timolol
are used topically in
glaucoma
(section
11.6).
PROPRANOLOL HYDROCHLORIDE
Indications
see under Dose
Cautions
see notes above; also avoid abrupt with-
drawal especially in ischaemic heart disease;
first-
degree AV block;
portal hypertension (risk of dete-
rioration in liver function);
diabetes;
history of
obstructive airways disease (introduce cautiously and
monitor lung function—see notes above); myasthenia
gravis;
symptoms of hypoglycaemia and thyrotoxic-
osis may be masked (also see notes above); psoriasis;
history of hypersensitivity—may increase sensitivity
to allergens and result in more serious hypersensi-
tivity response,
also may reduce response to adrena-
line (epinephrine) (see also section 3.4.3);
interac-
tions: Appendix 1 (beta-blockers),
important:
verapamil interaction,
see also p.
133
Contra-indications
asthma (but see notes above),
uncontrolled heart failure,
Prinzmetal’s angina,
marked bradycardia, hypotension,
sick sinus
syndrome,
second- or third- degree AV block,
cardiogenic shock,
metabolic acidosis,
severe per-
ipheral arterial disease;
phaeochromocytoma (apart
from specific use with alpha-blockers, see also notes
above)
Bronchospasm
Beta-blockers,
including those considered
to be cardioselective,
should usually be avoided in patients
with a history of asthma or bronchospasm.
However,
when
there is no alternative, a cardioselective beta-blocker can be
given to these patients with caution and under specialist
supervision.
Hepatic impairment
reduce oral dose
Renal impairment
manufacturer advises caution—
dose reduction may be required
Pregnancy
see notes above
Breast-feeding
see notes above
Side-effects
see notes above;
also gastro-intestinal
disturbances;
bradycardia,
heart failure,
hypotension,
conduction disorders,
peripheral vasoconstriction
(including exacerbation of intermittent claudication
and Raynaud’s phenomenon);
bronchospasm (see
above), dyspnoea;
headache,
fatigue,
sleep distur-
bances,
paraesthesia,
dizziness,
vertigo,
psychoses;
sexual dysfunction;
purpura,
thrombocytopenia;
visual disturbances;
exacerbation of psoriasis,
alo-
pecia;
rarely
rashes and dry eyes (reversible on
withdrawal);
overdosage: see Emergency Treatment
of Poisoning,
p.
37
Dose
. By mouth,
hypertension,
initially 80 mg twice daily,
increased at weekly intervals as required;
mainte-
nance 160–320 mg daily
Prophylaxis of variceal bleeding in portal hyper-
tension, initially 40 mg twice daily, increased to 80 mg
twice daily according to heart rate; max. 160 mg twice
daily
Phaeochromocytoma (only with an alpha-blocker),
60 mg daily for 3 days before surgery
or
30 mg daily in
patients unsuitable for surgery
Angina,
initially 40 mg 2–3 times daily;
maintenance
120–240 mg daily
Arrhythmias,
hypertrophic cardiomyopathy,
anxiety
tachycardia, and thyrotoxicosis (adjunct), 10–40 mg
3–4 times daily
Anxiety with symptoms such as palpitation, sweating,
tremor,
40 mg once daily,
increased to 40 mg 3 times
daily if necessary
Prophylaxis after myocardial infarction, 40 mg 4 times
daily for 2–3 days, then 80 mg twice daily, beginning 5
to 21 days after infarction
Essential tremor,
initially 40 mg 2–3 times daily;
maintenance 80–160 mg daily
Migraine prophylaxis,
80–240 mg daily in divided
doses
. By intravenous injection,
arrhythmias and thyrotoxic
crisis,
1 mg over 1 minute;
if necessary repeat at 2-
minute intervals; max.
total dose 10 mg (5 mg in
anaesthesia)
Note
Excessive bradycardia can be countered with intra-
venous injection of atropine sulphate 0.6–2.4 mg in divided
doses of 600 micrograms; for overdosage see Emergency
Treatment of Poisoning,
p.
37
Propranolol
(Non-proprietary) A
Tablets
,
propranolol hydrochloride 10 mg,
net price
28 = 92p; 40 mg, 28 = 93p; 80 mg, 56 = £1.54; 160 mg,
56 = £4.02.
Label:
8
Brands include
Angilol
c
Oral solution
, propranolol hydrochloride 5 mg/5 mL,
net price 150 mL = £12.50;
10 mg/5 mL,
150 mL =
£16.45;
50 mg/5 mL,
150 mL = £19.98.
Label:
8
Brands include
Syprol
c
Inderal
c
(AstraZeneca) A
Injection
,
propranolol hydrochloride 1 mg/mL,
net
price 1-mL amp = 21p
Modified release
Note
Modified-release preparations can be used for once daily
administration
Half-Inderal LA
c
(AstraZeneca) A
Capsules
,
m/r,
lavender/pink,
propranolol hydro-
chloride 80 mg,
net price 28-cap pack = £5.40.
Label:
8,
25
Note
Modified-release capsules
containing propranolol
hydro-
chloride 80 mg also available;
brands include
Bedranol SR
c
,
Half Beta Prograne
c
Inderal-LA
c
(AstraZeneca) A
Capsules
,
m/r,
lavender/pink,
propranolol hydro-
chloride 160 mg,
net price 28-cap pack = £1.91.
Label:
8,
25
Note
Modified-release capsules
containing propranolol
hydro-
chloride 160 mg also available;
brands include
Bedranol SR
c
,
Beta Prograne
c
,
Slo-Pro
c
BNF 61
2.4 Beta-adrenoceptor blocking drugs
99
2
Cardiovascular system