Propranolol (capsule): Difference between revisions

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{{Propranolol}}
{{DrugProjectFormSinglePage
{{Drugbox| verifiedrevid = 464216937
|genericName=generic name
| IUPAC_name = (''RS'')-1-(1-methylethylamino)-3-(1-naphthyloxy)propan-2-ol
|aOrAn=a
| drug_name = Propranolol
|drugClass=Adrenergic receptor agonist
|indication=a list of indications, separated by commas.
|hasBlackBoxWarning=Yes
|adverseReactions=a list of adverse reactions, separated by commas.
|blackBoxWarningTitle=Warning Title
|blackBoxWarningBody=<i><span style="color:#FF0000;">Condition Name:</span></i> (Content)
|fdaLIADAdult======Condition 1=====


<!--Clinical data-->
* Dosing Information
| brand = Inderal
 
| Drugs.com = {{drugs.com|monograph|propranolol-hydrochloride}}
:* (Dosage)
| licence_US = Propranolol
 
| pregnancy_AU = C
=====Condition 2=====
| pregnancy_US = C
 
| legal_AU = S4
* Dosing Information
| legal_UK = POM
 
| legal_US = Rx-only
:* (Dosage)
| routes_of_administration = Oral, anal, [[intravenous|IV]]
|offLabelAdultGuideSupport======Condition 1=====
 
* Developed by: (Organisation)
 
* Class of Recommendation: (Class) (Link)
 
* Strength of Evidence: (Category A/B/C) (Link)
 
* Dosing Information/Recommendation
 
:* (Dosage)
 
=====Condition 2=====
 
* Developed by: (Organisation)
 
* Class of Recommendation: (Class) (Link)
 
* Strength of Evidence: (Category A/B/C) (Link)
 
* Dosing Information/Recommendation
 
:* (Dosage)
|offLabelAdultNoGuideSupport======Condition 1=====
 
* Dosing Information
 
:* (Dosage)
 
=====Condition 2=====
 
* Dosing Information
 
:* (Dosage)
 
=====Condition 3=====
 
* Dosing Information
 
:* (Dosage)
|fdaLIADPed======Condition 1=====
 
* Dosing Information
 
:* (Dosage)
 
=====Condition 2=====
 
* Dosing Information
 
:* (Dosage)
|offLabelPedGuideSupport======Condition 1=====
 
* Developed by: (Organisation)
 
* Class of Recommendation: (Class) (Link)
 
* Strength of Evidence: (Category A/B/C) (Link)
 
* Dosing Information/Recommendation
 
:* (Dosage)
 
=====Condition 2=====
 
* Developed by: (Organisation)
 
* Class of Recommendation: (Class) (Link)
 
* Strength of Evidence: (Category A/B/C) (Link)
 
* Dosing Information/Recommendation
 
:* (Dosage)
|offLabelPedNoGuideSupport======Condition 1=====
 
* Dosing Information
 
:* (Dosage)
 
=====Condition 2=====
 
* Dosing Information
 
:* (Dosage)
 
=====Condition 3=====
 
* Dosing Information
 
:* (Dosage)
|contraindications=* Condition 1
* Condition 2
* Condition 3
* Condition 4
* Condition 5
|warnings======Conidition 1=====
 
(Description)
 
|clinicalTrials=======Central Nervous System======
 
: (list/description of adverse reactions)
 
======Cardiovascular======
 
: (list/description of adverse reactions)
 
======Respiratory======
 
: (list/description of adverse reactions)
 
======Gastrointestinal======
 
: (list/description of adverse reactions)
 
======Hypersensitive Reactions======
 
: (list/description of adverse reactions)
 
======Miscellaneous======
 
: (list/description of adverse reactions)
 
=====Condition 2=====
 
======Central Nervous System======
 
: (list/description of adverse reactions)
 
======Cardiovascular======
 
: (list/description of adverse reactions)
 
======Respiratory======
 
: (list/description of adverse reactions)
 
======Gastrointestinal======
 
: (list/description of adverse reactions)
 
======Hypersensitive Reactions======
 
: (list/description of adverse reactions)
 
======Miscellaneous======
 
: (list/description of adverse reactions)
|postmarketing=(Description)
|drugInteractions=* Drug 1
* Drug 2
* Drug 3
* Drug 4
* Drug 5
 
=====Drug 1=====
 
(Description)
 
=====Drug 2=====
 
(Description)
 
=====Drug 3=====
 
(Description)
 
=====Drug 4=====
 
(Description)
 
=====Drug 5=====
 
(Description)
|useInPregnancyFDA=(Description)
|useInPregnancyAUS=(Description)
|useInLaborDelivery=(Description)
|useInNursing=(Description)
|useInPed=(Description)
|useInGeri=(Description)
|useInGender=(Description)
|useInRace=(Description)
|useInRenalImpair=(Description)
|useInHepaticImpair=(Description)
|useInReproPotential=(Description)
|useInImmunocomp=(Description)
|othersTitle=Others
|useInOthers=(Description)
 
|administration=(Oral/Intravenous/etc)
|monitoring======Condition 1=====
 
(Description regarding monitoring, from ''Warnings'' section)
 
=====Condition 2=====
 
(Description regarding monitoring, from ''Warnings'' section)
 
=====Condition 3=====
 
(Description regarding monitoring, from ''Warnings'' section)
|IVCompat====Solution===


<!--Pharmacokinetic data-->
====Compatible====
| bioavailability = 26%
| metabolism = [[hepatic]] (extensive)
| elimination_half-life = 4–5 hours
| excretion = [[renal]] <1%


<!--Identifiers-->
* Solution 1
| CASNo_Ref = {{cascite|correct|CAS}}
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| CAS_number_Ref = {{cascite|correct|??}}
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| CAS_number = 525-66-6
| ATC_prefix = C07
| ATC_suffix = AA05
| PubChem = 4946
| IUPHAR_ligand = 564
| DrugBank_Ref = {{drugbankcite|correct|drugbank}}
| DrugBank = DB00571
| ChemSpiderID_Ref = {{chemspidercite|correct|chemspider}}
| ChemSpiderID = 4777
| UNII_Ref = {{fdacite|correct|FDA}}
| UNII = 9Y8NXQ24VQ
| KEGG_Ref = {{keggcite|correct|kegg}}
| KEGG = D08443
| ChEBI_Ref = {{ebicite|correct|EBI}}
| ChEBI = 8499
| ChEMBL_Ref = {{ebicite|correct|EBI}}
| ChEMBL = 27


<!--Chemical data-->
====Not Tested====
| C=16 | H=21 | N=1 | O=2
| molecular_weight = 259.34 g/mol
| smiles = CC(C)NCC(COc1cccc2c1cccc2)O
| InChI = 1/C16H21NO2/c1-12(2)17-10-14(18)11-19-16-9-5-7-13-6-3-4-8-15(13)16/h3-9,12,14,17-18H,10-11H2,1-2H3
| StdInChI_Ref = {{stdinchicite|correct|chemspider}}
| StdInChI = 1S/C16H21NO2/c1-12(2)17-10-14(18)11-19-16-9-5-7-13-6-3-4-8-15(13)16/h3-9,12,14,17-18H,10-11H2,1-2H3
| StdInChIKey_Ref = {{stdinchicite|correct|chemspider}}
| StdInChIKey = AQHHHDLHHXJYJD-UHFFFAOYSA-N


}}
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__NOTOC__
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{{CMG}}
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'''''For patient information about Propranolol, click [[Propranolol (patient information)|here]].'''''
====Variable====


{{SB}} Inderal LA<sup>®</sup>, InnoPran XL<sup>®</sup>
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==Overview==
====Incompatible====


'''Propranolol''' ([[International Nonproprietary Name|INN]]) is a [[sympatholytic]] non-selective [[beta blocker]]. Sympatholytics are used to treat hypertension, anxiety and panic. It was the first successful beta blocker developed.<ref name="Black JW, Crowther AF, Shanks RG, Smith LH, Dornhorst AC 1964 1080–1081">{{cite journal|author=Black JW, Crowther AF, Shanks RG, Smith LH, Dornhorst AC |title=A new adrenergic betareceptor antagonist | journal=[[The Lancet]] |volume=283 |issue=7342 |pages=1080–1081 |year=1964 |pmid=14132613 |doi=10.1016/S0140-6736(64)91275-9}}</ref>  Propranolol is available in generic form as Propranolol Hydrochloride; marketed in India under brand names like Ciplar and '''Ciplar LA''' by [[Cipla]], also other brands from [[AstraZeneca]] and [[Wyeth]] under brand names Inderal, Inderal LA, Avlocardyl, Deralin, Dociton, Inderalici, InnoPran XL, Sumial, Anaprilinum, Bedranol SR ([[Sandoz]]).
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==Category==
===Y-Site===


Beta-blockers, Antimigraine drugs
====Compatible====


==FDA Package Insert==
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====INDERAL LA (propranolol hydrochloride) capsule, extended release====
====Not Tested====


'''  [[Propranolol indications and usage|Indications and Usage]]'''
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'''| [[Propranolol dosage and administration|Dosage and Administration]]'''
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'''| [[Propranolol contraindications|Contraindications]]'''
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'''| [[Propranolol warnings and precautions|Warnings and Precautions]]'''
'''| [[Propranolol adverse reactions|Adverse Reactions]]'''
'''| [[Propranolol drug interactions|Drug Interactions]]'''
'''| [[Propranolol use in specific populations|Use in Specific Populations]]'''
'''| [[Propranolol overdosage|Overdosage]]'''
'''| [[Propranolol description|Description]]'''
'''| [[Propranolol clinical pharmacology|Clinical Pharmacology]]'''
'''| [[Propranolol nonclinical toxicology|Nonclinical Toxicology]]'''
'''| [[Propranolol how supplied storage and handling|How Supplied/Storage and Handling]]'''
'''| [[Propranolol labels and packages|Labels and Packages]]'''


== Medical uses ==
====Variable====


Propranolol is indicated for the management of various conditions including:
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* [[Hypertension]]
====Incompatible====
* [[Angina pectoris]]
* [[Tachyarrhythmia]]s
* [[Myocardial infarction]]
* Control of [[tachycardia]]/tremor associated with [[anxiety]], [[hyperthyroidism]] or [[Lithium pharmacology|lithium therapy]]
* [[Essential tremor]]
* [[Migraine]] prophylaxis<ref>{{cite journal |last1=Shields |first1=Kevin G. |coauthors=Peter J. Goadsby |date=January 2005 |title=Propranolol modulates trigeminovascular responses in thalamic ventroposteromedial nucleus: a role in migraine? |journal=[[Brain (journal)|Brain]]|volume=128 |issue=1 |pages=86–97 |doi=10.1093/brain/awh298 |url=http://brain.oxfordjournals.org/content/128/1/86.full |accessdate=17 August 2012}}</ref><ref>{{cite book |title=The Biochemistry of Migraine |last=Eadie |first=M. |coauthors=J. H. Tyrer |year=1985 |publisher=Springer |location=New York |isbn=9780852007310 |page=148 |oclc=11726870 |url=http://books.google.com/books?id=JYeyCc9M6acC&pg=PA148&lpg=PA148&dq=Propranolol+migraine+mechanism,&source=bl&ots=Ep2oSjxpAo&sig=7H_KHF3xoIP0nBKJJaqsDl_IhAs&hl=en&ei=TXVPTuu6DKHE4gT6gLnXBw&sa=X&oi=book_result&ct=result&resnum=4&ved=0CCoQ6AEwAzgK#v=onepage&q=Propranolol%20migraine%20mechanism%2C&f=false}}{{dead link|date=August 2012}}</ref>
* [[Cluster headaches]] prophylaxis
* [[Tension headache]] (Off label use)
* Shaky hands
* Hyperhidrosis


There has been some experimentation in psychiatric areas:<ref name="pmid17200914">{{cite journal |author=Kornischka J, Cordes J, Agelink MW |title=[40 years beta-adrenoceptor blockers in psychiatry] |language=German |journal=Fortschritte Der Neurologie-Psychiatrie |volume=75 |issue=4 |pages=199–210 |date=April 2007 |pmid=17200914 |doi=10.1055/s-2006-944295}}</ref> 
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* Treating the excessive drinking of fluids in [[psychogenic polydipsia]]<ref name="pmid7737786">{{cite journal |doi=10.2190/5WG5-VV1V-BXAD-805K |author=Vieweg V, Pandurangi A, Levenson J, Silverman J |title=The consulting psychiatrist and the polydipsia-hyponatremia syndrome in schizophrenia |journal=International Journal of Psychiatry in Medicine |volume=24 |issue=4 |pages=275–303 |year=1994 |pmid=7737786}}</ref><ref name="pmid9844835">{{cite journal |doi=10.2190/QPWL-14H7-HPGG-A29D |author=Kishi Y, Kurosawa H, Endo S |title=Is propranolol effective in primary polydipsia? |journal=International Journal of Psychiatry in Medicine |volume=28 |issue=3 |pages=315–25 |year=1998 |pmid=9844835}}</ref>
===Admixture===


* [[Antipsychotic]]-induced [[akathisia]]<ref name="pmid2577308">{{cite journal |author=Kramer MS, Gorkin R, DiJohnson C |title=Treatment of neuroleptic-induced akathisia with propranolol: a controlled replication study |journal=The Hillside Journal of Clinical Psychiatry |volume=11 |issue=2 |pages=107–19 |year=1989 |pmid=2577308}}</ref>
====Compatible====


* [[Aggressive behavior]] of patients with [[Acquired brain injury|brain injuries]]<ref name="pmid7903928">{{cite journal |author=Thibaut F, Colonna L |title=[Anti-aggressive effect of beta-blockers] |language=French |journal=L'Encéphale |volume=19 |issue=3 |pages=263–7 |year=1993 |pmid=7903928}}</ref>
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* [[Post-traumatic stress disorder]]
====Not Tested====
* Calming down individuals with [[phobias]] via sedative effects
* Performance anxiety
* [[Glaucoma]]
* [[Thyrotoxicosis]]  via deiodinase inhibition
* Primary exertional headache<ref>[http://www.medlink.com/medlinkcontent.asp Clinical summary]</ref>


While once first-line treatment for [[hypertension]], the role for beta-blockers was downgraded in June 2006 in the [[United Kingdom]] to fourth-line as they do not perform as well as other drugs, particularly in the elderly, and evidence is increasing that the most frequently used beta-blockers at usual doses carry an unacceptable risk of provoking [[Diabetes mellitus type 2|type 2 diabetes]].<ref>{{cite web | author= Sheetal Ladva | title=NICE and BHS launch updated hypertension guideline | url=http://www.nice.org.uk/download.aspx?o=335988 | date=2006-06-28 | publisher=[[National Institute for Health and Clinical Excellence]] | accessdate=2009-10-11}}</ref>
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Propranolol is also used to lower [[Hepatic portal vein|portal vein]] pressure in [[portal hypertension]] and prevent [[esophageal varices|esophageal variceal]] bleeding and [[ascites]].
====Variable====


===Off-label and investigational use===
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Propranolol is often used by musicians and other performers to prevent [[stage fright]]. It has been taken by surgeons to reduce their own innate [[tremor|hand tremors]] during surgery.<ref>{{cite journal |author=Elman MJ, Sugar J, Fiscella R, ''et al.'' |title=The effect of propranolol versus placebo on resident surgical performance |journal=Transactions of the American Ophthalmological Society |volume=96 |issue= |pages=283–91; discussion 291–4 |year=1998 |pmid=10360293 |pmc=1298399}}</ref>
====Incompatible====


Propranolol is currently being investigated as a potential treatment for [[post-traumatic stress disorder]].<ref>{{cite web |url=http://www.msnbc.msn.com/id/10806799/ |title=Doctors test a drug to ease traumatic memories - Mental Health - MSNBC.com |accessdate=2007-06-30 |work=}}</ref><ref>{{cite journal |author=Brunet A, Orr SP, Tremblay J, Robertson K, Nader K, Pitman RK |title=Effect of post-retrieval propranolol on psychophysiologic responding during subsequent script-driven traumatic imagery in post-traumatic stress disorder |journal=Journal of Psychiatric Research |volume=42 |issue=6 |pages=503–6 |date=May 2008 |pmid=17588604 |doi=10.1016/j.jpsychires.2007.05.006}}</ref><ref>[http://www.cbsnews.com/stories/2006/11/22/60minutes/main2205629.shtml?tag=contentMain;contentBody A pill to forget]</ref> Propranolol works to inhibit the actions of norepinephrine (noradrenaline), a neurotransmitter that enhances memory consolidation. Studies have shown that individuals given propranolol immediately after a traumatic experience show less severe symptoms of PTSD compared to their respective control groups that did not receive the drug (Vaiva et al., 2003){{full|date=November 2012}}. Propranolol reduces the effects of [[nightmare]]-related cardiac activity by keeping [[sinus rhythm]] low during nightmares, as a higher pulse and increased [[adrenaline]] are associated with severe nightmares. However, results remain inconclusive as to the success of propranolol in treatment of PTSD, including nightmares experienced by those with PTSD.
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Ethical and legal questions have been raised surrounding the use of Propranolol-based medications for use as a "memory dampener," including: altering (memory-recalled) evidence during an investigation, modifying behavioral response to past (albeit traumatic) experiences, the regulation of these drugs, and others.<ref>{{cite journal| author=Kolber, Adam J.| title=Therapeutic Forgetting: The Legal and Ethical Implications of Memory Dampening |journal=Vanderbilt Law Review, San Diego Legal Studies Paper No. 07-37. |volume=59 |page=1561 |year=2006}}</ref> However, Hall and Carter have argued that many such objections are "based on wildly exaggerated and unrealistic scenarios that ignore the limited action of propranolol in affecting memory, underplay the debilitating impact that PTSD has on those who suffer from it, and fail to acknowledge the extent to which drugs like alcohol are already used for this purpose." <ref>{{cite journal|last=Hall|first=Wayne|coauthors=Carter, Adrian | title=Debunking Alarmist Objections to the Pharmacological Prevention of PTSD |journal=American Journal of Bioethics|year=2007|volume=7|issue=9|pages=23 -25|doi=10.1080/15265160701551244|accessdate=8 December 2013}}</ref>   
===Syringe===


Propranolol in combination with etodolac is currently being investigated in a Phase 3 trial of 400 colorectal cancer patients as a potential treatment for prevention of colorectal cancer recurrence.<ref>{{cite web |url=http://clinicaltrials.gov/ct2/show/NCT00888797|title=β-adrenergic Blocker and a COX2 Inhibitor for Prevention of Colorectal Cancer Recurrence |accessdate=2010-07-19 |work=}}</ref> The aim of this study is to assess the use of perioperative medical intervention using a combination of a propranolol  and etodolac  in order to attenuate the surgically induced immunosuppression and other physiological perturbations, aiming to reduce the rate of tumor recurrence and distant metastatic disease.
====Compatible====


Starting in 2008, reports of successful use of propranolol to treat severe infantile [[hemangiomas]] (IHs) began to emerge. This treatment shows promise as being superior to corticosteroids when treating IHs. Extensive clinical case evidence and a small controlled trial support its efficacy.<ref>{{cite journal |journal= Current Dermatology Reports |year= 2012 |doi= 10.1007/s13671-012-0026-6 |title= Propranolol for Infantile Hemangiomas: A Review |first1= M. |last1= Hogeling |page= Online-first }}</ref>
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Propranolol was investigated for possible effects on resting energy expenditure and muscle catabolism in patients with severe burns.<ref>{{cite journal |author=Herndon DN et al. |title=Reversal of Catabolism by Beta-Blockade after Severe Burns|journal=New England Journal of Medicine |volume=345 |issue=17 |pages=1223–1229 |date=October 2001 |pmid=11680441 |doi=10.1056/NEJMoa010342}}</ref> In children with burns, treatment with propranolol during hospitalization attenuated hypermetabolism and reversed muscle wasting.
====Not Tested====


Propranolol along with a number of other membrane-acting drugs have been investigated for possible effects on ''[[Plasmodium falciparum]]'' and so the treatment of [[malaria]]. In vitro positive effects until recently had not been matched by useful in vivo anti-parasite activity against ''[[Plasmodium vinckei|P. vinckei]]'',<ref>{{cite journal |author=Ohnishi S, Sadanaga K, Katsuoka M, Weidanz W |title=Effects of membrane acting-drugs on plasmodium species and sickle cell erythrocytes |journal=Mol Cell Biochem |volume=91 |issue=1–2 |pages=159–65 |year=1990 |pmid=2695829 |doi=10.1007/BF00228091}}</ref> or ''[[Plasmodium yoelii|P. yoelii nigeriensis]]''.<ref>{{cite journal |author=Singh N, Puri S |title=Interaction between chloroquine and diverse pharmacological agents in chloroquine resistant Plasmodium yoelii nigeriensis |journal=Acta Trop |volume=77 |issue=2 |pages=185–93 |year=2000 |pmid=11080509 |doi=10.1016/S0001-706X(00)00133-9}}</ref> However, a single study from 2006 has suggested that propranolol may reduce the dosages required for existing drugs to be effective against ''P. falciparum'' by 5- to 10-fold, suggesting a role for combination therapies.<ref>{{cite journal |author=Murphy S, Harrison T, Hamm H, Lomasney J, Mohandas N, Haldar K |title=Erythrocyte G Protein as a Novel Target for Malarial Chemotherapy |journal=PLoS Med |volume=3 |issue=12 |pages=e528 |date=December 2006 | pmid=17194200 | doi= 10.1371/journal.pmed.0030528 |pmc=1716186}}</ref>
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Oxford researcher Sylvia Terbeck gave volunteers the beta-blocker propranolol. The volunteers scored lower on a range of psychological tests designed to reveal any racist attitudes than a group who took a placebo.<ref>{{cite web | author= Sheetal Ladva | title=Drug 'reduces implicit racial bias,' study suggests | url=http://www.ox.ac.uk/media/news_stories/2012/120803.html | date=2012-03-15 | publisher=[[Oxford Medical School]] | accessdate=2012-03-16}}</ref> The region of the brain called the amygdala is involved in processing emotion, including fear, and many psychologists think racist feelings are driven by the fear center. Propranolol inhibits the amygdala.<ref>[http://www.kplctv.com/story/17144764/medical-headliners-racism-pill-springing-forward-school-menus?clienttype=printable Pill for Racism]</ref>
====Variable====


In 2011, a small study conducted in two French allergy practices suggested that low doses of propranolol (10–40&nbsp;mg daily) were effective in the treatment of [[aquagenic pruritus]].<ref>Journal of Allergy and Clinical Immunology, May 2011</ref>
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Studies have found propranolol effectively decreases many of the side effects of [[marijuana]].<ref>{{cite pmid|403557}}</ref><ref>{{cite pmid|15131000}}</ref><ref>[http://archives.drugabuse.gov/pdf/monographs/68.pdf#page=117 Hollister, Leo E. "Interactions of cannabis with other drugs in man." Strategies for research on the interactions of drugs of abuse. National Institute on Drug Abuse Research monograph 68 (1986): 110-116.]</ref>
====Incompatible====


==Precautions and contraindications==
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Propranolol should be used with caution in people with:<ref name="Rossi">Rossi S, editor. [[Australian Medicines Handbook]] 2006. Adelaide: Australian Medicines Handbook; 2006.</ref>
===TPN/TNA===


*[[Diabetes mellitus]] or [[hyperthyroidism]], since signs and symptoms of [[hypoglycaemia]] may be masked.
====Compatible====
*[[Peripheral vascular disease]] and [[Raynaud's syndrome]], which may be exacerbated
*[[Phaeochromocytoma]], as [[hypertension]] may be aggravated without prior [[alpha blocker]] therapy
*[[Myasthenia gravis]], may be worsened
*Other drugs with [[bradycardia|bradycardic]] effects


Propranolol is contraindicated in patients with:<ref name="Rossi" />
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*Reversible airways disease, particularly [[asthma]] or [[chronic obstructive pulmonary disease]] (COPD)
====Not Tested====
*[[Bradycardia]] (<60 beats/minute)
*[[Sick sinus syndrome]]
*[[Atrioventricular block]] (second or third degree)
*[[shock (circulatory)|Shock]]
*Severe [[hypotension]]
*Cocaine toxicity [per American Heart Association guidelines, 2005]


==Adverse effects==
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Due to the high penetration across the [[blood brain barrier]], [[lipophilic]] beta blockers such as propranolol and [[metoprolol]] are more likely than other less lipophilic beta blockers to cause sleep disturbances such as insomnia and vivid dreams and nightmares.<ref name="pmid21180298">{{cite journal |author=Cruickshank JM |title=Beta-blockers and heart failure |journal=Indian Heart J |volume=62 |issue=2 |pages=101–10 |year=2010 |pmid=21180298 }}</ref>
====Variable====


[[Adverse drug reaction]]s (ADRs) associated with propranolol therapy are similar to other lipophilic beta blockers (''see [[beta blocker]]'').
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===Pregnancy and lactation===
====Incompatible====
Propranolol, like other beta blockers, is classified as [[pregnancy category]] C in the United States and [[Australian Drug Evaluation Committee|ADEC]] Category C in Australia. Beta-blocking agents in general reduce perfusion of the placenta which may lead to adverse outcomes for the [[neonate]], including [[human lung|pulmonary]] or [[human heart|cardiac]] complications, or premature birth. The newborn may experience additional adverse effects such as [[hypoglycemia]] and [[bradycardia]].<ref name="Martindale">{{Cite book|editor=Sweetman, Sean C. |chapter=Cardiovascular Drugs|title=[[Martindale: The complete drug reference]] |edition=36th |year=2009|pages=1226–1381|publisher=Pharmaceutical Press |location=London|isbn=978-0-85369-840-1}}</ref>


Most beta-blocking agents appear in the milk of [[lactation|lactating]] women. However, propranolol is highly [[plasma protein binding|bound to proteins in the bloodstream]] and is distributed into breast milk at very low levels.<ref name="LactMed">[No authors listed] (2007). "Propranolol". In: ''Drugs and Lactation Database.'' U.S. [[National Library of Medicine]] Toxicology Data Network. Retrieved 2013-02-25.</ref> These low levels are not expected to pose any risk to the breastfeeding infant, and the [[American Academy of Pediatrics]] considers propranolol therapy "generally compatible with breastfeeding."<ref name="LactMed"/><ref name="Martindale"/><ref>{{cite journal |author=[No authors listed] |title=Transfer of drugs and other chemicals into human milk |journal=Pediatrics |volume=108 |issue=3 |pages=776–89 |date=September 2001 |pmid=11533352}}</ref><ref>{{cite journal |author=Spencer JP, Gonzalez LS, Barnhart DJ |title=Medications in the breast-feeding mother |journal=Am Fam Physician |volume=64 |issue=1 |pages=119–26 |date=July 2001 |pmid=11456429}}</ref>
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|overdose====Acute Overdose===


==Pharmacokinetics==
====Signs and Symptoms====


Propranolol is rapidly and completely absorbed, with peak plasma levels achieved approximately 1–3 hours after ingestion. Co-administration with food appears to enhance [[bioavailability]]. Despite complete absorption, propranolol has a  variable [[bioavailability]] due to extensive [[first-pass metabolism]]. [[Hepatic]] impairment will therefore increase its bioavailability. The main metabolite 4-hydroxypropranolol, with a longer [[half-life]] (5.2–7.5 hours) than the parent compound (3–4 hours), is also pharmacologically active.
(Description)


Propranolol is a highly [[lipophilic]] drug achieving high concentrations in the brain. The duration of action of a single oral dose is longer than the half-life and may be up to 12 hours, if the single dose is high enough (e.g., 80&nbsp;mg). Effective plasma concentrations are between 10–100&nbsp;ng/mL.
====Management====


Toxic levels are associated with plasma concentrations above 2000&nbsp;ng/ml.
(Description)


==Mechanism of action==
===Chronic Overdose===


Propranolol is a [[beta blocker|non-selective beta blocker]], that is, it blocks the action of [[epinephrine]] and [[norepinephrine]] on both β<sub>1</sub>- and β<sub>2</sub>-[[adrenergic receptor]]s. It has little intrinsic sympathomimetic activity (ISA) but has strong membrane stabilizing activity (only at high blood concentrations, e.g. overdosage). Research has also shown that propranolol has inhibitory effects on the [[norepinephrine transporter]] and/or stimulates norepinephrine release (present experiments have shown that the concentration of norepinephrine is increased in the [[synapse]] but do not have the ability to discern which effect is taking place).<ref>{{cite journal |author=Young R, Glennon RA |title=S(-)Propranolol as a discriminative stimulus and its comparison to the stimulus effects of cocaine in rats |journal=Psychopharmacology (Berl.) |volume=203 |issue=2 |pages=369–82 |date=April 2009 |pmid=18795268 |doi=10.1007/s00213-008-1317-2 }}</ref> Since propranolol blocks β-adrenoceptors, the increase in synaptic norepinephrine only results in α-adrenergic activation, with the α1-adrenoceptor being particularly important for effects observed in animal models. Therefore, some have suggested that it be looked upon as an indirect α1 agonist as well as a β antagonist. Probably owing to the effect at the α1-adrenoceptor, the racemic and the individual enantiomers of propranolol have been shown to substitute for [[cocaine]] in rats, with the most potent enantiomer being S-(–)-propranolol. In addition, some evidence suggests that propranolol may function as a partial agonist at one or more serotonin receptors (possibly 5-HT<sub>1B</sub>).
====Signs and Symptoms====


Both enantiomers of the drug have a [[local anesthetic]] (topical) effect, which is normally mediated by blockade of voltage-gated sodium channels. Few studies have demonstrated propranolol's ability to block cardiac, neuronal, and skeletal voltage-gated sodium channels, accounting for its known "[[membrane stabilizing effect]]" and anti-arrhythmic and other central nervous system effects.<ref>{{cite journal | author = Wang D. W., Mistry A. M., Kahlig K. M., Kearney J. A., Xiang J., George A. L. Jr | year = 2010 | title = Propranolol blocks cardiac and neuronal voltage-gated sodium channels | url = | journal = Front. Pharmacol | volume = 1 | issue = | page = 144 | doi = 10.3389/fphar.2010.00144 }}</ref><ref>{{cite journal | author = Bankston J. R., Kass R. S. | year = 2010 | title = Molecular determinants of local anesthetic action of beta-blocking drugs: implications for therapeutic management of long QT syndrome variant 3 | url = | journal = J. Mol. Cell. Cardiol | volume = 48 | issue = | pages = 246–253 }}</ref><ref>{{cite journal | author = Desaphy J. F., Pierno S., De Luca A., Didonna P., Camerino D. C. | year = 2003 | title = Different ability of clenbuterol and salbutamol to block sodium channels predicts their therapeutic use in muscle excitability disorders | url = | journal = Mol. Pharmacol | volume = 63 | issue = | pages = 659–670 }}</ref>
(Description)


==Interactions==
====Management====


Since beta blockers are known to relax the cardiac muscle and to constrict the smooth muscle, these beta adrenergic antagonists, including propranolol, have an additive effect with other drugs which decrease blood pressure, or which decrease cardiac contractility or conductivity. Clinically significant interactions particularly occur with:<ref name="Rossi" />
(Description)
|drugBox={{Drugbox2
| verifiedrevid =
| IUPAC_name =
| image =
| drug_name =  


*[[verapamil]]
<!--Clinical data-->
*[[epinephrine]]
| tradename =  
*[[Beta2-adrenergic receptor agonist|β<sub>2</sub>-adrenergic receptor agonists]]
| MedlinePlus =  
**[[Salbutamol]], [[Levosalbutamol]], [[Formoterol]], [[Salmeterol]], etc.
| licence_US =  
*[[clonidine]]
| pregnancy_AU =  
*[[ergot alkaloid]]s
| pregnancy_US =  
*[[isoprenaline]]
| legal_status =  
*[[non-steroidal anti-inflammatory drug]]s
| routes_of_administration =
*[[quinidine]]
*[[cimetidine]]
*[[lidocaine]]
*[[phenobarbital]]
*[[rifampicin]]
*[[Fluvoxamine]] slows down the metabolism of propranolol significantly leading to increased blood levels of propranolol.<ref>{{cite journal |author=van Harten J |title=Overview of the pharmacokinetics of fluvoxamine |journal=Clinical Pharmacokinetics |volume=29 |issue=Suppl 1 |pages=1–9 |year=1995 |pmid=8846617 |doi=10.2165/00003088-199500291-00003}}</ref>


==Chemistry==
<!--Pharmacokinetic data-->
| bioavailability =  
| metabolism =  
| elimination_half-life =  
| excretion =  


Propranolol is synthesized in two ways from the same initial substance.<ref>A.F. Crowther, L.H. Smith, {{US Patent|3337628}} (1967)</ref><ref>A.F. Crowther, L.H. Smith, {{US Patent|3520919}} (1970)</ref><ref>A.F. Crowther, L.H. Smith, {{Cite patent|GB|994918}} (1963)</ref><ref>A.F. Crowther, L.H. Smith, {{Cite patent|DE|1493897}} (1963)</ref><ref>A.F. Crowther, L.H. Smith, {{Cite patent|BE|640312}} (1964)</ref><ref>A.F. Crowther, L.H. Smith, {{Cite patent|BE|640313}} (1964)</ref> The first way consists of reacting [[1-naphthol]] with [[epichlorohydrin]]. Opening of the [[epoxide]] ring gives 1-chloro-3-(1-naphthyloxy)-2-propanol, which is reacted further with [[isopropylamine]], giving propranolol. The second method uses the same reagents in the presence of a base and consists of initially making 3-(1-naphthyloxy)propylenoxide, the subsequent reaction with isopropylamine which results in [[epoxide]] ring opening leading to the formation of propranolol.
<!--Identifiers-->
| CAS_number_Ref =
| CAS_number =
| ATC_prefix =
| ATC_suffix =
| PubChem =
| IUPHAR_ligand =
| DrugBank_Ref =
| DrugBank =
| ChemSpiderID_Ref =
| ChemSpiderID =
| UNII_Ref =
| UNII =
| KEGG_Ref =
| KEGG =
| ChEBI_Ref =
| ChEBI =
| ChEMBL_Ref =
| ChEMBL =


==Historical Perspective==
<!--Chemical data-->
| C= | H= | N= | O=
| molecular_weight =
| smiles =
| InChI =
| InChIKey =
| StdInChI_Ref =
| StdInChI =
| StdInChIKey_Ref =
| StdInChIKey =
| melting_point =
}}
|mechAction=(Description)
|structure=(Description with picture)
|PD=(Description)
|PK=(Description)
|nonClinToxic=(Description)
|clinicalStudies======Condition 1=====


[[British people|British]] scientist [[James W. Black]] successfully developed propranolol in the 1960s.<ref name="Black JW, Crowther AF, Shanks RG, Smith LH, Dornhorst AC 1964 1080–1081"/> In 1988, he was awarded the [[Nobel Prize in Medicine]] for this discovery. Propranolol was derived from the early β-adrenergic antagonists [[dichloroisoprenaline]] and [[pronethalol]]. The key structural modification, which was carried through to essentially all subsequent beta blockers, was the insertion of an oxymethylene group into the [[aryl]][[ethanolamine]] structure of pronethalol thus greatly increasing the potency of the compound. This also apparently eliminated the [[carcinogenicity]] found with pronethalol in animal models.
(Description)


Newer, more selective beta-blockers (such as [[nebivolol]], [[carvedilol]], or [[metoprolol]]) are now used in the treatment of [[hypertension]].
=====Condition 2=====


==References==
(Description)


{{Reflist|2}}
=====Condition 3=====


[[Category:Drugs]]
(Description)
[[Category:Cardiovascular Drugs]]
|howSupplied=(Description)
[[Category:Beta blockers]]
|fdaPatientInfo=(Patient Counseling Information)
|nlmPatientInfo=(Link to patient information page)
|lookAlike=* (Paired Confused Name 1a) — (Paired Confused Name 1b)
* (Paired Confused Name 2a) — (Paired Confused Name 2b)
* (Paired Confused Name 3a) — (Paired Confused Name 3b)
|drugShortage=Drug Shortage
}}

Revision as of 13:46, 8 July 2014

Propranolol (capsule)
Black Box Warning
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];

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Black Box Warning

Warning Title
See full prescribing information for complete Boxed Warning.
Condition Name: (Content)

Overview

Propranolol (capsule) is a Adrenergic receptor agonist that is FDA approved for the {{{indicationType}}} of a list of indications, separated by commas.. There is a Black Box Warning for this drug as shown here. Common adverse reactions include a list of adverse reactions, separated by commas..

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Condition 1
  • Dosing Information
  • (Dosage)
Condition 2
  • Dosing Information
  • (Dosage)

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

Condition 1
  • Developed by: (Organisation)
  • Class of Recommendation: (Class) (Link)
  • Strength of Evidence: (Category A/B/C) (Link)
  • Dosing Information/Recommendation
  • (Dosage)
Condition 2
  • Developed by: (Organisation)
  • Class of Recommendation: (Class) (Link)
  • Strength of Evidence: (Category A/B/C) (Link)
  • Dosing Information/Recommendation
  • (Dosage)

Non–Guideline-Supported Use

Condition 1
  • Dosing Information
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Condition 2
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Condition 3
  • Dosing Information
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Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Condition 1
  • Dosing Information
  • (Dosage)
Condition 2
  • Dosing Information
  • (Dosage)

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

Condition 1
  • Developed by: (Organisation)
  • Class of Recommendation: (Class) (Link)
  • Strength of Evidence: (Category A/B/C) (Link)
  • Dosing Information/Recommendation
  • (Dosage)
Condition 2
  • Developed by: (Organisation)
  • Class of Recommendation: (Class) (Link)
  • Strength of Evidence: (Category A/B/C) (Link)
  • Dosing Information/Recommendation
  • (Dosage)

Non–Guideline-Supported Use

Condition 1
  • Dosing Information
  • (Dosage)
Condition 2
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Condition 3
  • Dosing Information
  • (Dosage)

Contraindications

  • Condition 1
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  • Condition 5

Warnings

Warning Title
See full prescribing information for complete Boxed Warning.
Condition Name: (Content)
Conidition 1

(Description)

Adverse Reactions

Clinical Trials Experience

Central Nervous System
(list/description of adverse reactions)
Cardiovascular
(list/description of adverse reactions)
Respiratory
(list/description of adverse reactions)
Gastrointestinal
(list/description of adverse reactions)
Hypersensitive Reactions
(list/description of adverse reactions)
Miscellaneous
(list/description of adverse reactions)
Condition 2
Central Nervous System
(list/description of adverse reactions)
Cardiovascular
(list/description of adverse reactions)
Respiratory
(list/description of adverse reactions)
Gastrointestinal
(list/description of adverse reactions)
Hypersensitive Reactions
(list/description of adverse reactions)
Miscellaneous
(list/description of adverse reactions)

Postmarketing Experience

(Description)

Drug Interactions

  • Drug 1
  • Drug 2
  • Drug 3
  • Drug 4
  • Drug 5
Drug 1

(Description)

Drug 2

(Description)

Drug 3

(Description)

Drug 4

(Description)

Drug 5

(Description)

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): (Description)
Pregnancy Category (AUS): (Description)

Labor and Delivery

(Description)

Nursing Mothers

(Description)

Pediatric Use

(Description)

Geriatic Use

(Description)

Gender

(Description)

Race

(Description)

Renal Impairment

(Description)

Hepatic Impairment

(Description)

Females of Reproductive Potential and Males

(Description)

Immunocompromised Patients

(Description)

Others

(Description)

Administration and Monitoring

Administration

(Oral/Intravenous/etc)

Monitoring

Condition 1

(Description regarding monitoring, from Warnings section)

Condition 2

(Description regarding monitoring, from Warnings section)

Condition 3

(Description regarding monitoring, from Warnings section)

IV Compatibility

Solution

Compatible

  • Solution 1
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Not Tested

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Variable

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Incompatible

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Y-Site

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Not Tested

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Variable

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Incompatible

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Admixture

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Variable

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Incompatible

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Syringe

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Variable

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Incompatible

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TPN/TNA

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Not Tested

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Variable

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Incompatible

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Overdosage

Acute Overdose

Signs and Symptoms

(Description)

Management

(Description)

Chronic Overdose

Signs and Symptoms

(Description)

Management

(Description)

Pharmacology

Propranolol (capsule)
Systematic (IUPAC) name
?
Identifiers
CAS number ?
ATC code ?
PubChem ?
Chemical data
Formula ?
Mol. mass ?
Pharmacokinetic data
Bioavailability ?
Metabolism ?
Half life ?
Excretion ?
Therapeutic considerations
Pregnancy cat.

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Legal status
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Mechanism of Action

(Description)

Structure

(Description with picture)

Pharmacodynamics

(Description)

Pharmacokinetics

(Description)

Nonclinical Toxicology

(Description)

Clinical Studies

Condition 1

(Description)

Condition 2

(Description)

Condition 3

(Description)

How Supplied

(Description)

Storage

There is limited information regarding Propranolol (capsule) Storage in the drug label.

Images

Drug Images

{{#ask: Page Name::Propranolol (capsule) |?Pill Name |?Drug Name |?Pill Ingred |?Pill Imprint |?Pill Dosage |?Pill Color |?Pill Shape |?Pill Size (mm) |?Pill Scoring |?NDC |?Drug Author |format=template |template=DrugPageImages |mainlabel=- |sort=Pill Name }}

Package and Label Display Panel

{{#ask: Label Page::Propranolol (capsule) |?Label Name |format=template |template=DrugLabelImages |mainlabel=- |sort=Label Page }}

Patient Counseling Information

(Patient Counseling Information)

Precautions with Alcohol

Alcohol-Propranolol (capsule) interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Propranolol (capsule) Brand Names in the drug label.

Look-Alike Drug Names

  • (Paired Confused Name 1a) — (Paired Confused Name 1b)
  • (Paired Confused Name 2a) — (Paired Confused Name 2b)
  • (Paired Confused Name 3a) — (Paired Confused Name 3b)

Drug Shortage Status

Drug Shortage

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

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