• Hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma (all but Hemangeol).
• Prevention and management of MI, and the prevention of vascular headaches (all but Hemangeol).
• Proliferating infantile hemangioma requiring systemic therapy (Hemangeol only)

Unlabeled Uses:

• Also used to manage alcohol withdrawal, aggressive behavior, antipsychotic-associated akathisia, situational anxiety, and esophageal varices.
• Post-traumatic stress disorder (PTSD).

Contraindicated in:

• Hypersensitivity
• Uncompensated HF
• Pulmonary edema
• Cardiogenic shock
• Bradycardia, sick sinus syndrome, or heart block (unless pacemaker present)
• Premature infants with corrected age <5 wk (Hemangeol only)
• Asthma or history of bronchospasm (Hemangeol only)
• BP <50/30 mmHg (Hemangeol only)
• Pheochromocytoma (Hemangeol only)
• Pedi: Infants <2 kg (Hemangeol only).

Use Cautiously in:

• Renal or hepatic impairment
• Pulmonary disease (including asthma)
• Diabetes mellitus (may mask signs of hypoglycemia)
• Thyrotoxicosis (may mask symptoms)
• History of severe allergic reactions (may ↑ intensity of response)
• Skeletal muscle disease (may exacerbate myopathy)
• OB: Crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression. May also ↓ blood supply to the placenta, ↑ the risk for premature birth or fetal death, and cause intrauterine growth retardation. May ↑ risk of cardiac and pulmonary complications in the infant during the neonatal time frame. Lactation: Safety not established in breastfeeding
• Pedi: ↑risk of hypoglycemia in children, especially during periods of fasting such as before surgery, during prolonged exertion, or with coexisting renal insufficiency
• Geri: Older adults may have ↑ sensitivity to beta blockers; initial dose reduction and careful titration recommended.

CV: ARRHYTHMIAS, BRADYCARDIA, HF, orthostatic hypotension, peripheral vasoconstriction, PULMONARY EDEMA.

Derm: ERYTHEMA MULTIFORME, EXFOLIATIVE DERMATITIS, itching, rash, STEVENS-JOHNSON SYNDROME (SJS), TOXIC EPIDERMAL NECROLYSIS.

EENT: blurred vision, dry eyes, nasal stuffiness.

Endo: hyperglycemia, hypoglycemia (↑ in children).

GI: constipation, diarrhea, nausea.

GU: erectile dysfunction, ↓ libido.

MS: arthralgia, back pain, muscle cramps, myopathy.

Neuro: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares, paresthesia.

Resp: bronchospasm, wheezing.
Misc: drug-induced lupus syndrome, (INCLUDING ANAPHYLAXIS)HYPERSENSITIVITY REACTIONS .

Drug-Drug:

• General anesthesia, IV phenytoin, and verapamil may cause additive myocardial depression.
• Additive bradycardia may occur with digoxin.
• Additive hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates.
• Levels may be ↓ with chronic alcohol use.
• Concurrent use with amphetamines, cocaine, ephedrine, epinephrine, norepinephrine, phenylephrine, or pseudoephedrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia).
• Concurrent thyroid administration may ↓ effectiveness.
• May alter the effectiveness of insulin or oral hypoglycemics (dose adjustments may be necessary).
• May ↓ effectiveness of beta-adrenergic bronchodilators and theophylline.
• May ↓ beneficial beta cardiovascular effects of dopamine or dobutamine.
• Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).
• Cimetidine may ↑ blood levels and toxicity.
• Concurrent NSAIDs may ↓ antihypertensive action.
• Smoking↑ metabolism and ↓ effects; smoking cessation may ↑ effects.
• May ↑ levels of lidocaine and bupivacaine.

(Generic available)

• Immediate-release tablets: 10 mg; 20 mg; 40 mg; 60 mg; 80 mg;
• Extended-release capsules: 60 mg; 80 mg; 120 mg; 160 mg;
• Oral solution: 20 mg/5 mL; 40 mg/5 mL;
• Oral solution (Hemangeol): 4.28 mg/mL;
• Solution for injection: 1 mg/mL;
• In combination with: hydrochlorothiazide (generic only).

• PO (Adults): Antianginal: 80–320 mg/day in 2–4 divided doses or once daily as extended/sustained-release capsules. Antihypertensive: 40 mg twice daily initially; may be ↑ as needed (usual range 120–240 mg/day; doses up to 1 g/day have been used); or 80 mg once daily as extended/sustained-release capsules, ↑ as needed up to 120 mg. InnoPran XL dosing form is designed to be given once daily at bedtime. Antiarrhythmic: 10–30 mg 3–4 times daily. Prevention of MI: 180–240 mg/day in divided doses. Hypertrophic cardiomyopathy: 20–40 mg 3–4 times daily. Adjunct therapy of pheochromocytoma: 20 mg 3 times daily to 40 mg 3–4 times daily concurrently with alpha-blocking therapy, started 3 days before surgery is planned. Vascular headache prevention: 20 mg 4 times daily or 80 mg/day as extended/sustained-release capsules; may be ↑ as needed up to 240 mg/day. Management of tremor: 40 mg twice daily; may be ↑ up to 120 mg/day (up to 320 mg have been used).
• PO (Children): Antihypertensive/antiarrhythmic: 0.5–1 mg/kg/day in 2–4 divided doses; may be ↑ as needed (usual range for maintenance dose is 2–4 mg/kg/day in 2 divided doses).
• PO (Children 5 wk–5 mo): Infantile hemangioma: 0.6 mg/kg twice daily (at least 9 hr apart); after 1 wk, ↑ to 1.1 mg/kg twice daily; after another wk, ↑ to 1.7 mg/kg twice daily and maintain for 6 mo.
• IV (Adults): Antiarrhythmic: 1–3 mg; may be repeated after 2 min and again in 4 hr if needed.
• IV (Children): Antiarrhythmic: 10–100 mcg (0.01–0.1 mg)/kg (up to 1 mg/dose); may be repeated every 6–8 hr if needed.

Hemangeol, Inderal, Inderal LA, Inderal XL, InnoPran XL

• Blocks stimulation of beta₁(myocardial) and beta₂ (pulmonary, vascular, and uterine)-adrenergic receptor sites; its mechanism for the treatment of infantile hemangiomas is unknown.

• Decreased heart rate and BP.
• Suppression of arrhythmias.
• Prevention of MI.
• Prevention of vascular headaches.
• Hemangioma resolution

Therapeutic Classification: antianginals, antiarrhythmics (Class II), antihypertensives, vascular headache suppressants

Pharmacologic Classification: beta blockers

Absorption: Well absorbed but undergoes extensive first-pass hepatic metabolism.

Distribution: Moderate CNS penetration. Crosses the placenta; enters breast milk.

Protein Binding: 93%.

Metabolism/Excretion: Almost completely metabolized by the liver (primarily for CYP2D6 isoenzyme) (the CYP2D6 enzyme system exhibits genetic polymorphism; 7% of population may be poor metabolizers and may have significantly ↑ propranolol concentrations and an ↑ risk of adverse effects).

Half-life: 3.4–6 hr.

(cardiovascular effects)

†Following single dose, full effect not seen until several wk of therapy.

• Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 4 hr before next dose (8 hr with extended-release propranolol). Inform patient that abrupt withdrawal can cause life-threatening arrhythmias, hypertension, or myocardial ischemia. Advise parent to read medication guide prior to starting and with each Rx refill in case of changes in Hemangeol.
• Advise patient to make sure enough medication is available for weekends, holidays, and vacations. A written prescription may be kept in wallet in case of emergency.
• Teach patient and family how to check pulse daily and BP biweekly. Advise patient to hold dose and contact health care professional if pulse is <50 bpm or BP changes significantly.
• May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness until response to the drug is known.
• Advise patients to change positions slowly to minimize orthostatic hypotension, especially during initiation of therapy or when dose is increased.
• Caution patient that this medication may increase sensitivity to cold.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products, especially NSAIDs and cold preparations, concurrently with this medication.
• Advise diabetic patients to closely monitor blood sugar, especially if weakness, malaise, irritability, or fatigue occurs. Medication may mask some signs of hypoglycemia, but dizziness and sweating may still occur. Acute hypertension may occur following insulin-induced hypoglycemia in patients receiving propranolol. Instruct parents/caregivers of children receiving Hemangeol how to recognize signs of hypoglycemia, and to notify health care professional and take child to nearest emergency department if hypoglycemia is suspected.
• Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
• Instruct patient to inform health care professional of medication regimen prior to treatment or surgery.
• Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Monitor neonates exposed to propranolol during pregnancy for bradycardia, hypotension, hypoglycemia, and respiratory depression. May also ↓ blood supply to placenta, ↑ risk for premature birth or fetal death, and cause intrauterine growth retardation. May ↑ risk of cardiac and pulmonary complications in the infant during the neonatal time frame.
• Advise patient to carry identification describing disease process and medication regimen at all times.
• Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.
• Angina: Caution patient to avoid overexertion with decrease in chest pain.
• Vascular Headache Prophylaxis: Caution patient that sharing this medication may be dangerous.
• PTSD: Advise patient that medication may relieve distressing symptoms but that psychotherapy is the primary treatment for the disorder. Refer patient and family to a PTSD support group.

proe-PRAN-oh-lole