Propranolol - EM Doctors

1. About propranolol

Propranolol belongs to a group of medicines called beta blockers. It's used to treat heart problems, help with anxiety and prevent migraines.

If you have a heart problem, you can take propranolol to:

treat high blood pressure
treat illnesses that cause an irregular heartbeat, like atrial fibrillation
prevent future heart disease, heart attacks and strokes
prevent chest pain caused by angina

Propranolol can help reduce your symptoms if you have too much thyroid hormone in your body (thyrotoxicosis). You'll usually take it together with medicines to treat an overactive thyroid.

This medicine is only available on prescription. It comes as tablets, capsules, or as a liquid to swallow

2. Key facts

Propranolol slows down your heart rate and makes it easier for your heart to pump blood around your body.
It is usually prescribed for high blood pressure and other heart problems, but it can also help with the physical signs of anxiety, like sweating and shaking.
Your very first dose of propranolol may make you feel dizzy, so take it at bedtime. After that, if you don't feel dizzy, you can take it in the morning.
The main side effects of propranolol are feeling dizzy or tired, cold hands or feet, difficulties sleeping and nightmares. These side effects are usually mild and short lived.
Propranolol is also called by the brand names Angilol, Bedranol, Beta-prograne, and Half Beta-prograne.

3. Who can and can't take propranolol

Propranolol can be taken by adults and children. But it is not officially approved for treating high blood pressure in children under 12 years old.

It isn't suitable for everyone. To make sure it is safe for you, tell your doctor before starting propranolol if you have:

had an allergic reaction to propranolol or any other medicine in the past
low blood pressure or a slow heart rate
heart failure which is getting worse
severe blood circulation problems in your limbs (such as Raynaud's phenomenon), which may make your fingers and toes tingle or turn pale or blue
metabolic acidosis - when there is too much acid in your blood
lung disease or asthma

Tell your doctor if you're trying to get pregnant, are already pregnant or if you're breastfeeding.

4. How and when to take it

Propranolol comes as 2 different types of medicine: standard release and sustained release (also called modified release).

Standard release - releases propranolol into your body quickly. You may need to take it several times a day depending on your dose.
Sustained release (SR) - this dissolves slowly so you don't have to take it as often. Once a day is usually enough.

If you are taking it once a day, your doctor may advise you to take your first dose before bedtime, because it can make you feel dizzy. After the first dose, if you don't feel dizzy, take propranolol in the morning.

Important

Keep taking propranolol even if you feel well. You will still be getting the benefits of the medicine.

How much will I take?

How much you take depends on why you need propranolol.

Doses for adults and children over the age of 12:

For high blood pressure, the starting dose is usually 80mg twice a day. If this dose isn't working well enough (if your blood pressure doesn't go down enough), your doctor may increase it to a maximum of 160mg twice a day.
For migraine or angina (chest pain), the usual dose is 40mg taken 2 or 3 times a day. This can be increased to 120mg to 240mg a day. Your doctor or pharmacist will explain how to split the dose over the day.
For irregular heartbeat (arrhythmia), the usual dose is 10mg to 40mg 3 or 4 times a day.
For anxiety, the usual dose is 40mg once a day which can be increased to 40mg 3 times a day.
For too much thyroid hormone (thyrotoxicosis), the dose is 10mg to 40mg taken 3 or 4 times a day.

Doses are usually lower for the elderly or people with a kidney or liver problem.

If your child is under 12 years old and they need propranolol, your doctor will usually use your child's weight to work out the right dose.

How to take it

Propranolol doesn't usually upset your tummy so you can take it with or without food. It's best to do the same each day.

Swallow the tablets whole with a drink of water. If you find them difficult to swallow, some brands have a score line to help you break the tablet in half. Check the information leaflet for your brand to see if you can do this.

If you're taking propranolol as a liquid, it will come with a plastic syringe or spoon to help you measure out the right dose. If you don't have one, ask your pharmacist for one. Don't use a kitchen teaspoon as it won't give you the right amount of medicine.

What if I forget to take it?

If you forget to take a dose of propranolol, take it as soon as you remember, unless it is nearly time for your next dose. In this case, just leave out the missed dose and take your next dose as normal.

Never take 2 doses at the same time. Never take an extra dose to make up for a forgotten one.

If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What if I take too much?

An overdose of propranolol can slow down your heart rate and make it difficult to breathe. It can also cause dizziness and trembling.

The amount of propranolol that can lead to an overdose varies from person to person.

Urgent advice: Call your doctor or go to A&E straight away if you take too much propranolol

If you need to go to hospital, don't drive yourself - get someone else to drive you or call for an ambulance. Take the propranolol packet or leaflet inside it plus any remaining medicine with you.

Find your nearest hospital A&E department.

5. Side effects

Like all medicines, propranolol can cause side effects in some people but many people have no side effects or only minor ones.

Side effects often improve as your body gets used to the medicine.

Common side effects

These common side effects happen in more than 1 in 100 people. They're usually mild and short lived.

Talk to your doctor or pharmacist if the side effects bother you or last more than a few days:

feeling tired, dizzy or light headed (these can be signs of a slow heart rate)
cold fingers or toes (propranolol may affect the blood supply to your hands and feet)
difficulties sleeping or nightmares
feeling sick (nausea)

Serious side effects

It happens rarely, but some people have serious side effects when taking propranolol.

Tell a doctor straight away if you have:

shortness of breath with a cough which gets worse when you exercise (like walking up stairs), swollen ankles or legs, chest pain, or an irregular heartbeat - these are signs of heart problems
shortness of breath, wheezing and tightening of your chest - these can be signs of lung problems
yellow skin or the whites of your eyes turn yellow - these can be signs of liver problems

Serious allergic reaction

In rare cases, propranolol may cause a serious allergic reaction (anaphylaxis).

Immediate action required: Call 999 or go to A&E if:

you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you're wheezing
you get tightness in the chest or throat
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling

You could be having a serious allergic reaction and may need immediate treatment in hospital.

These are not all the side effects of propranolol. For a full list, see the leaflet inside your medicine packet.

You can report any suspected side effect to the UK safety scheme.

6. How to cope with side effects

What to do about:

feeling tired, dizzy or light headed - as your body gets used to propranolol, these side effects should wear off. If propranolol makes you feel dizzy, sit or lie down until you feel better. Try to avoid alcohol as it will make you feel worse.
cold fingers or toes - put your hands or feet under warm running water, massage them and wiggle your fingers and toes. Do not smoke or have drinks with caffeine in - this can make your blood vessels narrower and further restrict blood flow to your hands and feet. Try wearing mittens (they're warmer than gloves) and warm socks. Do not wear tight watches or bracelets.
difficulties sleeping or nightmares - try taking your propranolol in the morning. If you have to take it more than once a day, speak to your doctor. They may be able to change your propranolol to the slow release form.
feeling sick (nausea) - stick to simple meals and don't eat rich or spicy food. It might help to take your propranolol after a meal or snack.

7. Pregnancy and breastfeeding

Propranolol isn't thought to be harmful during pregnancy, but it is not possible to be certain. So if you're trying to get pregnant or you're already pregnant, talk to your doctor about the benefits and possible harms of taking propranolol. There may be other medicines that are safer for you.

For more information about how propranolol can affect you and your baby during pregnancy, visit the Best Use of Medicines in Pregnancy (BUMPS) website.

Propranolol and breastfeeding

It is usually safe to take propranolol if you're breastfeeding. This is because only small amounts get into breast milk, which is not enough to cause any problems to your baby.

However, speak to your doctor before taking propranolol if your baby was premature or has any health problems.

Important

Tell your doctor if you're trying to get pregnant, are already pregnant or if you're breastfeeding.

8. Cautions with other medicines

There are some medicines that may interfere with the way propranolol works.

Tell your doctor if you're taking:

other medicines for high blood pressure. The combination with propranolol can sometimes lower your blood pressure too much. This may make you feel dizzy or faint. If this keeps happening to you, tell your doctor - they may change your dose.
other medicines for an irregular heartbeat such as amiodarone or flecainide
other medicines which can lower your blood pressure. These include some antidepressants, nitrates (for chest pain), baclofen (a muscle relaxant), medicines for an enlarged prostate gland like tamsulosin, or Parkinson's disease medicines such as levodopa.
medicines for asthma or chronic obstructive pulmonary disease (COPD)
medicines for diabetes, particularly insulin - propranolol may make it more difficult to recognise the warning signs of low blood sugar. Speak to your doctor if you have low blood sugar levels without getting any of the usual warning signs. You should check your blood sugar after exercise, and follow usual advice about checking it before driving, or operating machinery.
medicines to treat nose or sinus congestion, or other cold remedies (including those you can buy in the pharmacy)
medicines for allergies, such as ephedrine, noradrenaline or adrenaline
non-steroidal anti-inflammatory medicines (NSAIDs), such as ibuprofen, diclofenac and naproxen. These medicines may increase your blood pressure, so it's best to keep them to a minimum.

Mixing propranolol with herbal remedies or supplements

There's very little information about taking herbal remedies and supplements with propranolol.

Important

For safety, tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements.

9. Common questions

How does propranolol work?

Propranolol is a type of medicine called a beta blocker.

Like other beta blockers, propranolol works by changing the way your body responds to some nerve impulses, including in the heart. It slows down your heart rate and makes it easier for your heart to pump blood around your body.

It works differently if you're using it for anxiety. When you are anxious, your brain makes chemical messengers called adrenaline and noradrenaline. These make your heart rate faster and make you sweat or shake. Propranolol helps block the effects of these chemical messengers. This reduces the physical signs of anxiety.

We don't fully understand how propranolol prevents migraines. It may work by relaxing the blood vessels involved, or by reducing activity in the "visual cortex". This is the part of the brain where migraines are believed to start.

How long does propranolol take to work?

Propranolol usually starts to work in a few hours.

For heart conditions or high blood pressure - propranolol can take up to a week to reach its full effect. You may not feel any different but that doesn't mean it isn't working. It's important to keep taking your medicine.
For migraines - it can take several weeks for propranolol to start making a real difference, so keep taking it.

How long will I take it for?

This depends on why you're taking propranolol.

For heart conditions or high blood pressure - treatment is usually long term and may be for the rest of your life.
For anxiety - propranolol is usually taken short term, to help with your physical symptoms. Speak to your doctor about the pros and cons of taking it for more than a few months. This will depend on your symptoms, whether it's a one-off or a recurring problem, how well propranolol works for you and whether you get side effects.
For migraines - treatment can last for several months or years, depending on how bad your symptoms are.

Is it safe to take for a long time?

Propranolol is generally safe to take for a long time.

If you're taking it for a heart condition, or to prevent migraines, it works best when you take it long term.

If you're taking it for anxiety, there don't seem to be any lasting harmful effects if you take it for several months or years. However, it's best to take propranolol only for as long as you need it.

You'll need to have your blood pressure checked regularly if you're taking propranolol for a long time for migraines or anxiety.

What will happen if I stop taking it?

Talk to your doctor if you want to stop taking propranolol. If you're bothered by side effects, your doctor may be able to prescribe a different medicine instead.

Stopping propranolol suddenly may make your health problem worse. In addition, if you stop suddenly after taking it for a long time, you may get extra side effects as a reaction to stopping it. These include an irregular heart rate, sweating and shaking.

If you stop taking propranolol, it will take about 1 to 2 days for it to be completely out of your body but the side effects can last for up to 1 week.

How does propranolol compare with other heart medicines?

Propranolol works as well as other beta blockers for reducing blood pressure. The main difference between propranolol and other beta blockers is that it doesn't just affect your heart. It can affect other parts of your body too, such as your lungs.

There are lots of other medicines to lower your blood pressure and treat chest pain. They work in a different way to beta blockers and include:

ACE inhibitors - for example ramipril and lisinopril
angiotensin receptor blockers - for example candesartan
calcium channel blockers - for example amlodipine
diuretics (medicines which make you pee more) - for example furosemide

Beta blockers aren't usually the first choice treatment for high blood pressure. The medicine your doctor prescribes depends on your age and ethnicity.

If you're under 55, you'll usually be offered an ACE inhibitor or an angiotensin receptor blocker.
If you're 55 or older, or you're any age and of African Caribbean or black African origin, you'll usually be offered a calcium channel blocker.

Sometimes you may have to try other blood pressure-lowering medicines if you get side effects. Many people need to take a combination of different blood pressure-lowering tablets.

How does it compare with other medicines for preventing migraine?

Atenolol, metoprolol, timolol and nadolol are all beta blockers and they work well in preventing migraines. However, most doctors prescribe propranolol.

There are some other medicines that are known to prevent migraines but they are not officially approved in the UK. They include amitriptyline, sodium valproate and gabapentin and they may have different side effects.

Topiramate can also be used to prevent migraines. It works just as well as propranolol. However, topiramate has not been officially approved for migraine for children under the age of 16.

Ask your doctor or pharmacist which medicine is best for you.

How does it compare with other medicines for anxiety?

Propranolol treats the physical symptoms of anxiety - for example, it stops your heart beating too fast. You'll usually only take propranolol for a short time.

The physical symptoms of anxiety are caused by chemical imbalances in the brain. Your doctor may prescribe an antidepressant like sertraline to treat these imbalances. You usually take antidepressants long term.

Many doctors prefer drug-free treatments. These include talking therapies like cognitive behavioural therapy. If you're having talking therapy, your doctor may prescribe propranolol at the same time. This will help you with your physical symptoms.

Will I need to stop propranolol before surgery?

Can I drink alcohol with it?

Is there any food or drink I need to avoid?

Will it make me put on weight?

Some people on propranolol say they put on weight, especially in the first few months of taking it. This isn't known to be a common side effect of taking propranolol, however, and there isn't enough information to say for sure why some people put on weight.

It could, for example, be because propranolol can make you feel tired which could make you less active. It could also affect the way your body uses energy.

If you're worried about putting on weight with propranolol, speak to your doctor.

Will it affect my contraception?

Propranolol won't stop your contraception working.

However, some types of hormonal methods of contraception, like the combined pill and contraceptive patch, aren't usually recommended for women taking propranolol and other medicines for high blood pressure. This is because some hormonal contraceptives can raise your blood pressure and stop propranolol working properly.

Talk to your doctor if you're taking a hormonal contraceptive.

Will it affect my fertility?

Will it affect my sex life?

Do I need to avoid playing sports?

Can I drive or ride a bike?

Can lifestyle changes help?

If you have heart problems, you can boost the health of your heart by making some key lifestyle changes. These will also help if you have high blood pressure.

Quit smoking - smoking increases your heart rate and blood pressure. Quitting smoking brings down your blood pressure and relieves heart failure symptoms. Try to avoid secondhand smoke.
Cut down on alcohol - drinking alcohol while you're taking propranolol can make you feel dizzy or light headed. Also drinking too much alcohol raises blood pressure over time and makes heart failure worse. Men and women shouldn't drink more than 14 units of alcohol a week. A standard glass of wine (175ml) is 2 units. A pint of lager or beer is usually 2 to 3 units of alcohol.
Exercise - regular exercise lowers blood pressure by keeping your heart and blood vessels in good condition. It doesn't need to be too energetic - walking every day will help.
Eat well - aim to eat a diet that includes plenty of fruit and veg, wholegrains, fat-free or low-fat dairy products and lean proteins. It's a good idea to cut down on salt too. Eating too much salt is the biggest cause of high blood pressure - the more salt you eat, the higher your blood pressure will be. Aim for no more than 6g of salt a day.
Deal with stress - when you're anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. This can make heart failure worse too. Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible. Spend time with friends and family to be social and help avoid stress.

If you get severe headaches, there are steps you can take to help prevent migraines. This includes working out what things trigger an attack so you can avoid them.