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An 80 mg capsule of propranolol Propranolol (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.[1] 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).
Medical uses
Propranolol is indicated for the management of various conditions including:
- Hypertension
- Angina pectoris
- Tachyarrhythmias
- Myocardial infarction
- Control of tachycardia/tremor associated with anxiety, hyperthyroidism or lithium therapy.
- Essential tremor
- Migraine prophylaxis
- Cluster headaches prophylaxis
- Tension headache (Off label use)
- Shaky hands
- Hyperhidrosis
- There has been some experimentation in psychiatric areas:
- Treating the excessive drinking of fluids in psychogenic polydipsia,
- Antipsychotic-induced akathisia,
- Aggressive behavior of patients with brain injuries
- Post-traumatic stress disorder
- Calming down individuals with phobias via sedative effects
- Performance anxiety
- Glaucoma
- Thyrotoxicosis via deiodinase inhibition
- Primary exertional headache
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 type 2 diabetes.
Propranolol is also used to lower portal vein pressure in portal hypertension and prevent esophageal variceal bleeding and ascites.
Other uses
Propranolol is often used by musicians and other performers to prevent stage fright. It has been taken by surgeons to reduce their own innate hand tremors during surgery.
Propranolol is currently being investigated as a potential treatment for post-traumatic stress disorder. 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. 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.
Ethical and legal questions have been raised surrounding the use of Propranolol-based medications for use as a "memory damper," including: altering (memory-recalled) evidence during an investigation, modifying behavioral response to past (albeit traumatic) experiences, the regulation of these drugs, and others. 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."
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. 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.
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.
Propranolol was investigated for possible effects on resting energy expenditure and muscle catabolism in patients with severe burns. In children with burns, treatment with propranolol during hospitalization attenuated hypermetabolism and reversed muscle wasting.
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 P. vinckei, or P. yoelii nigeriensis. 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.
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. 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.
In 2011, a small study conducted in two French allergy practices suggested that low doses of propranolol (10–40 mg daily) were effective in the treatment of aquagenic pruritus.
Studies have found propranolol effectively decreases many of the side effects of marijuana.
Precautions and contraindications
Propranolol should be used with caution in people with:
- Diabetes mellitus or hyperthyroidism, since signs and symptoms of hypoglycaemia may be masked.
- 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 bradycardic effects
Propranolol is contraindicated in patients with:
- Reversible airways disease, particularly asthma or chronic obstructive pulmonary disease (COPD)
- Bradycardia (<60 beats/minute)
- Sick sinus syndrome
- Atrioventricular block (second or third degree)
- Shock
- Severe hypotension
- Cocaine toxicity [per American Heart Association guidelines, 2005]
Adverse effects
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.
Adverse drug reactions (ADRs) associated with propranolol therapy are similar to other lipophilic beta blockers (see beta blocker).
Pregnancy and lactation
Propranolol, like other beta blockers, is classified as pregnancy category C in the United States and 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 pulmonary or cardiac complications, or premature birth. The newborn may experience additional adverse effects such as hypoglycemia and bradycardia.
Most beta-blocking agents appear in the milk of lactating women. However, propranolol is highly bound to proteins in the bloodstream and is distributed into breast milk at very low levels. 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."
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