Propranolol (Inderal)

ED / ICU / Transport

• Supraventricular tachycardia (SVT): short-term ventricular rate control, or conversion, when vagal maneuvers and adenosine have failed or are not an option. The IV use is on the FDA label.
• Atrial fibrillation (AF) or flutter with rapid ventricular response, no pre-excitation: For acute rate control in stable patients. Beta-blockers and diltiazem (only if ejection fraction >40%) are ACC/AHA Class 1 options.
• Thyroid storm: Core adrenergic control. High oral doses also slow T4-to-T3 conversion.
• Resistant tachyarrhythmias from excess catecholamine action during anesthesia: Endogenous or infused catecholamines, once other measures have failed. FDA-labeled.
• Digitalis-induced tachyarrhythmias: The label is for slowing the ventricular rate. digoxin immune Fab is the antidote when digoxin toxicity threatens life.
• Catecholamine- or digitalis-induced ventricular tachycardia: On the label, but not the first choice for other VT. Unstable? Use cardioversion.
• Persistent premature ventricular contractions (PVCs): IV, for PVCs that impair well-being and do not respond to conventional measures. FDA-labeled.

Other Uses

• Chronic oral therapy: hypertension (not for hypertensive emergencies), angina, post-myocardial infarction (MI), migraine prophylaxis, essential tremor, hypertrophic subaortic stenosis
• Pheochromocytoma: only as an adjunct after alpha-blockade
• Portal hypertension in cirrhosis: A nonselective beta-blocker (NSBB) given to prevent variceal bleeding and decompensation. In compensated cirrhosis, carvedilol is preferred (off-label).
• Proliferating infantile hemangioma: Hemangeol oral solution, on the FDA label for starting at 5 weeks to 5 months of age. Effectiveness is not established beyond 1 year.
• Performance anxiety: Off-label. The evidence is weak, and the overdose risk is high.

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

• Injection: 1 mg/mL in 1 mL (1 mg) single-dose vial, IV only. This is the form ED, ICU and transport use.
• Immediate-release (IR) tablets: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg.
• Extended-release (ER) capsules: Inderal LA 60 mg, 80 mg, 120 mg, 160 mg (once daily); InnoPran XL and Inderal XL 80 mg, 120 mg (once daily at bedtime).
• Hemangeol oral solution (infants): 4.28 mg/mL propranolol hydrochloride, with a dosing syringe.

Adult Dosing

Pediatric Dosing

Preparation & Administration

• Push rate: Keep it at no faster than 1 mg (1 mL) per minute. Faster pushes risk hypotension and cardiac standstill.
• Timing: Let each dose reach its site of action before you judge it. Poor circulation means waiting longer. Recheck HR and BP before the next dose.
• Monitoring during the push: continuous ECG and BP; atropine and pacing ready.
• Stopping point: give no more once the desired rate or rhythm is reached; move to oral therapy as soon as possible.
• Pump requirement: Any infusion (the off-label thyroid storm consensus option) runs on a smart pump.
• Hemangeol: give with the supplied oral syringe directly into the mouth; it may be mixed in a small amount of milk or fruit juice.

Contraindications

• Cardiogenic shock
• Sinus bradycardia, or atrioventricular (AV) block greater than first degree without a functioning pacemaker
• Bronchial asthma
• Hypersensitivity to propranolol
• Pre-excited AF or flutter (Wolff-Parkinson-White, WPW): ACC/AHA Class 3: Harm for all AV-nodal blockers. Differs from FDA label: the injection label still names WPW as an indication.
• Overt decompensated HF: avoid
• Hemangeol (infants): corrected age <5 weeks, weight <2 kg, asthma or prior bronchospasm, HR <80/min, AV block beyond first degree, decompensated HF, BP <50/30 mmHg, pheochromocytoma

Precautions

• COPD or bronchospastic disease (relative): It blunts the bronchodilation from beta-agonists.
• Diabetes, fasting, infants and children: hypoglycemia is the risk, and tachycardia and tremor are masked.
• Thyrotoxicosis and coronary disease: stopping it abruptly can trigger thyroid storm, angina or MI.
• Anaphylaxis history: reactions may be more severe, and usual epinephrine doses may not work.
• Pheochromocytoma: only after alpha-blockade. Cocaine or stimulant toxicity: AHA 2025 Part 10 does not recommend beta-blockers for cocaine-induced coronary vasospasm or hypertensive emergencies (COR 3: No Benefit, C-LD).
• Large facial infantile hemangioma: screen for PHACE syndrome (with arterial anomalies). A BP fall can cause stroke.

Hold / Reassess If

• Symptomatic bradycardia, HR below the ordered limit, or new second- or third-degree AV block: stop; atropine, pacing
• SBP <90 mmHg, MAP <65 mmHg (or ordered limits) or symptomatic hypotension: stop IV dosing
• New wheeze, crackles or rising oxygen need: stop and reassess
• Infant on Hemangeol: HR <80/min, SBP <50 mmHg, symptomatic bradycardia or hypotension, hypoglycemia, or wheeze with a chest infection: stop. Withhold doses during fasting, vomiting, infection, cold or stress

Common

• Bradycardia and hypotension are the most common events with IV use.
• Fatigue, lethargy, light-headedness
• Cold extremities, Raynaud-type arterial insufficiency
• Nausea, vomiting, diarrhea
• Vivid dreams, insomnia, depression
• Infants on Hemangeol (over 10%): sleep disturbance, worse bronchitis or bronchiolitis, diarrhea, vomiting

Serious / Life-Threatening

Overdose & Toxicity Management

• Signs: Bradycardia, AV block, hypotension and cardiogenic shock. QRS widening and ventricular dysrhythmias from sodium-channel blockade. Seizures and coma. Hypoglycemia. Extended-release capsules take hours to peak (InnoPran XL 12–14 hr), so toxicity can be delayed.
• Immediate care: airway, IV access, continuous ECG, glucose. Call poison control (1-800-222-1222). It is not significantly dialyzable, and hemodialysis (COR 2b) is reserved for atenolol, nadolol or sotalol.
• Bradycardia: Treat it with standard ALS (atropine, pacing), as for any bradycardia. AHA 2025 Part 10 no longer lists them as a beta-blocker recommendation. Capture can fail. Glucagon for symptomatic bradycardia is COR 2a (below).
• Vasopressors (COR 1, C-EO): Give them early for hypotension. Norepinephrine or epinephrine are almost always first-line. Differs from FDA label: the label says epinephrine is not indicated in propranolol overdose, given the unopposed alpha effect. The label also says dobutamine and isoproterenol reverse beta-blockade. Choose with toxicology or medical control.
• Refractory hypotension: high-dose insulin 1 unit/kg IV, then 1–10 units/kg/hr with dextrose, same per kg in children (COR 1, C-LD), once vasopressors are not enough.
• Glucagon: glucagon 2–10 mg IV, child 0.05–0.15 mg/kg, then 1–15 mg/hr in adults (COR 2a, C-LD). Differs from FDA label: the label gives 50–150 mcg/kg IV, then 1–5 mg/hr. Plan for vomiting.
• Calcium: may be reasonable (COR 2b, C-EO): calcium chloride 2 g IV (child 20 mg/kg, not above the adult dose), titrated to blood pressure.
• Wide QRS or ventricular dysrhythmia: sodium bicarbonate (COR 2a, C-EO) for sodium-channel blocker poisoning other than tricyclics.
• Refractory cardiogenic shock: venoarterial extracorporeal membrane oxygenation (VA-ECMO, COR 2a: C-LD adults, C-EO children). Lipid emulsion: COR 2b (C-EO). Its usefulness is uncertain, and it is not routine.

Clinically Significant Interactions

IV Compatibility

• The injection label has no diluent or Y-site compatibility data.
• Push through a line with no other drug running, or check compatibility first.
• Verify with an institutional compatibility resource.

• Pediatrics: IV use is not established. The label does not recommend the injection for pediatric arrhythmias. Hemangeol is the labeled infant product. Children have more hypoglycemia, especially when fasting, and bronchospasm and HF have also been reported. See the Pediatric Dosing table.
• Neonates: Hemangeol is contraindicated below a corrected age of 5 weeks or a weight of 2 kg. Newborns exposed at delivery can develop bradycardia, hypoglycemia and respiratory depression. Monitor at birth.
• Pregnancy: It crosses the placenta. Growth restriction, small placentas and congenital abnormalities have been reported. ACC/AHA AF guidance rates propranolol as reasonable first-line rate control in pregnancy. In an emergency, give it when the benefit justifies the risk.
• Lactation: It is excreted in breast milk. Use it with caution and watch the infant.
• Older Adults: Clearance is lower and the half-life is longer (oral 11 vs 5 hr; IV 254 vs 152 min). Start at the low end and allow longer between doses.
• Renal Impairment: The label gives no dose adjustment. Still, in a small study, peak levels ran 2–3 times higher in chronic renal failure (tablet and injection labels; 3–5 times in the XL labels), and clearance dropped. Titrate cautiously. Hypoglycemia is reported. It is not significantly dialyzable.
• Hepatic Impairment: In cirrhosis, the half-life rises (11 vs 4 hr) and unbound drug triples. Lower the IV dose. With ascites, Baveno VII advises reducing or stopping the NSBB when SBP <90 mmHg, MAP <65 mmHg or hepatorenal acute kidney injury occurs. Restart it once the patient has recovered.
• Obesity / Dosing Weight: Adult doses are fixed, not weight-based. Obese patients had higher exposure and lower clearance after IV dosing, so titrate to effect.
• Thyroid Disease: It masks thyrotoxicosis, and abrupt withdrawal can bring on thyroid storm. It alters thyroid tests. T4 and reverse T3 go up, and T3 goes down.

• Scope: EMS rarely carries it. ED and ICU RNs give it, as do critical-care transport teams, or it arrives already running at interfacility transfer. It varies by state and agency protocol.
• Storage & Stability: Store at 20–25°C (68–77°F). Protect it from freezing and excessive heat, including vehicle heat.
• Carried Concentration: 1 mg/mL, 1 mL vial: each vial is a 1 mg dose. Never draw up oral-strength amounts for IV use.
• No quick offset: Each IV dose keeps working for hours. If BP or ventricular function is uncertain, talk esmolol through with medical control.
• Infusions in Transport: A propranolol infusion is off-label, backed only by the thyroid storm consensus. Esmolol is the usual titratable choice. Smart pump, dedicated line, concentration confirmed at handoff.
• Handoff Essentials: dose times and total IV mg (and when the 4-hr window ends), HR and BP response, last oral dose and formulation (IR vs ER), other nodal blockers given, glucose, and ingestion details for overdoses.

Mechanism of Action

• Beta-1 block (heart): It slows sinus and ectopic pacemakers and AV-nodal conduction, which gives rate control. Less contractility leads to HF when reserve is minimal.
• Beta-2 block (bronchi, vessels): Smooth muscle in the airways and vessels constricts. That means bronchospasm, cold extremities and a blunted response to beta-agonists.
• No alpha block or intrinsic sympathomimetic activity: Alpha responses stay intact. That leaves an unopposed alpha effect with epinephrine.
• Membrane (sodium-channel) effect above beta-blocking doses: In overdose, that shows up as QRS widening and seizures.
• Thyroid: High doses slow peripheral T4-to-T3 conversion.

Pharmacokinetics

• Half-life: distribution 5–10 min; elimination 2–5.5 hr IV, 3–6 hr oral IR, about 8–10 hr ER (InnoPran XL and Inderal XL about 8 hr; Inderal LA about 10 hr).
• Metabolism: Extensive hepatic first pass leaves oral bioavailability at about 25%. CYP2D6, CYP1A2 and CYP2C19 do the metabolizing. Protein-rich food raises bioavailability by about 50%.
• Active metabolites: 4-hydroxypropranolol.
• Elimination: Metabolites leave in the urine. It is not significantly dialyzable.
• Protein binding / Vd: About 90% protein bound, with a volume of distribution of 4–5 L/kg. It crosses the blood-brain barrier and placenta and enters breast milk.

Generic Name

Propranolol hydrochloride

Brand Names

Inderal LA, Inderal XL, InnoPran XL (extended-release capsules); Hemangeol (infant oral solution); Inderal (original brand); generic tablets and injection

Pharmacologic Class

Nonselective beta-adrenergic blocker (class II antiarrhythmic)

Therapeutic Class

Antiarrhythmic; antihypertensive; antianginal; migraine prophylaxis

Controlled Substance

Not controlled

ISMP High-Alert

Yes: ISMP high-alert medication (adrenergic antagonists, IV)

Look-Alike / Sound-Alike

Inderal / Adderall