PROPRANOLOL

Posology For oral administration. Dosage requires individual adjustment. A heart rate of 55/minute or less is an indication that dosage should be increased no further. 5 mg/kg body weight three or four times daily. Migraine: children under the age of 12 may be given 20 mg two or three times daily.

Older children may be given adult dosage. Adults Hypertension: initially 80 mg twice daily, increased where necessary at weekly intervals. The usual maintenance dosage is 160 - 320 mg daily. Lower doses may be effective when a diuretic or other antihypertensive drug is given concurrently.

Angina pectoris: initially 40 mg twice or three times daily, increased by the same amount at weekly intervals. Control is usually achieved at a dose in the range 120 - 240 mg per day. Prophylaxis against recurrence of myocardial infarction: for long term prevention of sudden cardiac death in patients who have survived the acute phase of myocardial infarction.

Treatment should be commenced five to twenty one days after the infarction at a dose of 40 mg four times daily which should then be maintained for two or three days. Subsequently this dose may then be given as 80 mg twice per day to simplify compliance.

As the over-riding principle is to maintain adequate beta- blockade the dose may need to be varied for some patients. Anxiety: 40 mg daily may be used for immediate relief of acute situational anxiety. Longer term treatment for generalised anxiety should begin with 40 mg twice daily, which may be increased on an individual basis to 40 mg three times per day.

Continued treatment should be determined by response. After six months to one year the patient should be reviewed. Migraine, essential tremor: 40 mg twice or three times daily; increments at weekly intervals if needed to a daily total of 80 - 160 mg.

Dysrhythmias, anxiety tachycardia, hypertrophic obstructive cardiomyopathy, thyrotoxicosis: 10 - 40 mg three or four times daily. Elderly No specific dosage recommendations. However the optimum dose should be determined individually according to clinical response.

In patients with impaired renal function a reduced dosage should be considered initially.

Dry eyes and skin rash have been reported during treatment with -adrenergic blocking agents. If these symptoms are not attributable to some other cause, propranolol should be withdrawn. Rarely hypotension and bradycardia are the result of intolerance, in which case propranolol should be discontinued, with treatment for overdose if required.

Propranolol may cause or precipitate Raynaud's phenomenon, intermittent claudication or peripheral arterial insufficiency. Bronchospasm may occur, particularly in patients with a history of asthma (sometimes with a fatal outcome) or hay fever.

There have been rare reports of blood dyscrasias during treatment propranolol. Other effects that have been reported include: heart failure deterioration; heart block; postural hypotension, associated syncope; psychoses and hallucinations; nightmares; confusion; visual disturbances; mood changes; dizziness; thrombocytopenia, purpura; alopecia; aggravation of psoriasis or the production of psoriasiform skin reactions; paraesthesia.

In addition to the above propranolol may produce an increase in antinuclear antibody (ANA) levels. Hypoglycaemia in children may occur (frequency is not known), seizure linked to hypoglycaemia (frequency is not known). Isolated reports of myasthenia gravis like syndrome or exacerbation of myasthenia gravis have been reported.

Minor side effects include cold extremities, nausea, vomiting, diarrhoea, fatigue or insomnia. These are usually transient and are less common if the drug is introduced gradually. Where it is considered necessary to cease treatment, propranolol should be withdrawn gradually.

Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Although propranolol is contra-indicated in uncontrolled heart failure, it may be used in patients whose signs of heart failure have been controlled. In patients whose cardiac reserve is poor, caution must be advised. Particular care should be taken in the elderly and in other patients where renal or hepatic clearance may be reduced thus requiring an appropriate reduction in dosage.

In cases of decompensated cirrhosis propranolol should be used with caution. Propranolol should be withdrawn 24 hours before elective surgery, as it may interfere with response to stress. If this cannot be done, 1-2 mg atropine should be given intravenously before anaesthesia commences and anaesthetics such as ether, chloroform, cyclopropane and trichloroethylene, which may cause myocardial depression, should not be used.

Treatment with beta-blocking agents must not be stopped suddenly. If it is necessary to withdraw propranolol, this should be done gradually, or another beta-blocker should be substituted. Bradycardia and hypotension are usually a sign of overdosage, but may rarely be due to intolerance of the drug.

In the latter case propranolol should be withdrawn and, if necessary, the patient should be treated as for overdosage. Heart block and congestive heart failure have been reported due to propranolol. There have been reports suggesting that treatment with propranolol may increase the risk of developing hepatic encephalopathy.

In patients with portal hypertension, liver function may deteriorate and hepatic encephalopathy may develop. Propranolol, in common with other beta-adrenoceptor blocking drugs:- - may exacerbate less severe peripheral arterial circulatory disturbances; - if given to patients with first degree heart block, should be administered with caution (because of the negative effect on conduction time); - may modify the tachycardia of hypoglycaemia; - may conceal signs of thyrotoxicosis; - reduces heart rate - where, rarely, symptoms attributable to this develop, dosage should be reduced.

History of bronchospasm or asthma. The label will state - Do not take this medicine if you have a history of wheezing or asthma. Propranolol, in common with other beta-adrenoceptor blockers, is contraindicated in the following circumstances: prolonged fasting; metabolic acidosis; hypersensitivity; hypotension; severe peripheral arterial circulatory disturbance; cardiogenic shock; bradycardia; Prinzmetal's angina; uncontrolled heart failure; second or third degree heart block; untreated phaeochromocytoma; sick sinus syndrome.