English

ThisiscontentfromElsevier'sDrugInformation

Propranolol

Learn more about Elsevier's Drug Information today! Get the drug data and decision support you need, including TRUE Daily Updates™ including every day including weekends and holidays.

Aug.12.2023

Propranolol

Indications/Dosage

Labeled

  • acute myocardial infarction
  • angina
  • atrial fibrillation
  • atrial flutter
  • hemangioma
  • hypertension
  • idiopathic hypertrophic subaortic stenosis (IHSS)
  • migraine prophylaxis
  • pheochromocytoma
  • reduction of cardiovascular mortality
  • supraventricular tachycardia (SVT)
  • tremor

NOTE: Similar clinical efficacy (e.g., exercise tolerance, chest pain, blood pressure or heart rate control) are seen with equivalent daily doses of sustained-release propranolol (Inderal LA) compared to regular-release propranolol tablets (given in divided doses).

Off-Label

  • agitation
  • anxiety
  • burns
  • heart failure
  • premature ventricular contractions (PVCs)
  • scleroderma renal crisis
  • tetralogy spells
  • thyrotoxicosis
  • unstable angina
  • variceal bleeding prophylaxis
† Off-label indication

For the treatment of chronic stable angina

Oral dosage (immediate-release formulations)

Adults

Initially, 10 to 20 mg PO 2 to 4 times per day, then increase at 3 to 7 day intervals up to 160 to 320 mg/day, given in 2 to 4 divided doses. In geriatric patients, begin with conservative initial doses and titrate carefully; the elderly have unpredictable responses to beta-blockers.

Oral dosage (extended-release capsules)

Adults

80 mg PO once daily, then increase at 3 to 7 day intervals up to 160 to 320 mg PO once daily. In geriatric patients, begin with conservative initial doses and titrate carefully; the elderly have unpredictable responses to beta-blockers.

For the treatment of unstable angina†

Intravenous dosage

Adults

0.5 to 1 mg IV, followed in 1 to 2 hours by a switch to oral therapy. Per clinical practice guidelines, the intravenous dose can be reserved for high-risk patients and eliminated from the regimen in intermediate- and low-risk patients.[23966] In geriatric patients, use conservative dose; the elderly have unpredictable responses to beta-blockers.

Oral dosage (immediate-release formulations)

Adults

40 to 80 mg PO every 6 to 8 hours; begin 1 to 2 hours after initial IV therapy. Per clinical practice guidelines, the intravenous dose can be reserved for high-risk patients and eliminated from the regimen in intermediate- and low-risk patients.[23966] In geriatric patients, begin with conservative initial doses and titrate carefully; the elderly have unpredictable responses to beta-blockers.

For the treatment of atrial fibrillation and/or atrial flutter

Intravenous dosage

Adults

1 mg IV every 2 minutes as needed for up to 3 doses.[56966] [66054] The FDA-approved dosage is 1 to 3 mg IV every 2 minutes for 2 doses with further doses given after 4 hours or more. Reserve use for atrial fibrillation or flutter that is unresponsive to standard therapy or when more prolonged control is required.[45870] Guidelines recommend IV beta-blockers to slow the ventricular response to atrial fibrillation in the acute setting in the absence of pre-excitation and to slow rapid ventricular response with acute coronary syndrome and no heart failure, hemodynamic instability, or bronchospasm.[56966] [65848]

Children† and Adolescents†

0.01 mg/kg/dose IV every 6 to 8 hours as needed. May titrate dosage gradually as needed for clinical effect. Max: 0.15 mg/kg/dose or 3 mg/dose, whichever is less.[51735]

Infants†

0.01 mg/kg/dose IV every 6 to 8 hours as needed. May titrate dosage gradually as needed for clinical effect. Max: 0.15 mg/kg/dose or 1 mg/dose, whichever is less.[51735] [53734]

Neonates†

0.01 mg/kg/dose IV every 6 to 8 hours as needed. May titrate dosage gradually as needed for clinical effect. Max: 0.15 mg/kg/dose or 1 mg/dose, whichever is less.[51735] [53734]

Oral dosage (immediate-release)

Adults

10 to 40 mg PO 3 or 4 times daily.[28271] [56966] Guidelines recommend the use of beta blockers to control the ventricular rate for patients with paroxysmal, persistent, or permanent atrial fibrillation.[56966]

Infants†, Children†, and Adolescents†

0.5 to 1 mg/kg/day PO divided every 6 to 8 hours, initially. Increase the dose by 1 mg/kg/day every 3 to 5 days as needed for clinical effect. Usual dose: 2 to 4 mg/kg/day. Max: 16 mg/kg/day or 60 mg/day, whichever is less.[51735] [53675] [53676] In older adolescents, 10 to 30 mg/dose PO every 6 to 8 hours may be given.[53680]

Neonates†

0.5 to 1 mg/kg/day PO divided every 6 to 8 hours, initially. Increase the dose by 1 mg/kg/day every 3 to 5 days as needed for clinical effect. Usual dose: 2 to 4 mg/kg/day. Max: 16 mg/kg/day or 60 mg/day, whichever is less.[51735] [53675] [53676]

For the treatment of supraventricular tachycardia (SVT)

Intravenous dosage

Adults

1 mg IV every 2 minutes as needed for up to 3 doses.[45870] [65743] The FDA-approved dosage is 1 to 3 mg IV every 2 minutes for 2 doses with further doses given after 4 hours or more.[45870]

Children† and Adolescents†

0.01 mg/kg/dose IV every 6 to 8 hours as needed. May titrate dosage gradually as needed for clinical effect. Max: 0.15 mg/kg/dose or 3 mg/dose, whichever is less.[51735]

Infants†

0.01 mg/kg/dose IV every 6 to 8 hours as needed. May titrate dosage gradually as needed for clinical effect. Max: 0.15 mg/kg/dose or 1 mg/dose, whichever is less.[51735] [53734]

Neonates†

0.01 mg/kg/dose IV every 6 to 8 hours as needed. May titrate dosage gradually as needed for clinical effect. Max: 0.15 mg/kg/dose or 1 mg/dose, whichever is less.[51735] [53734]

Oral dosage (immediate-release)†

Adults

10 mg PO 3 to 4 times daily, initially. Adjust dose as needed based on response. Max: 160 mg/day.[65743]

Infants, Children, and Adolescents

0.5 to 1 mg/kg/day PO divided every 6 to 8 hours, initially. Increase the dose by 1 mg/kg/day every 3 to 5 days as needed for clinical effect. Usual dose: 2 to 4 mg/kg/day. Max: 16 mg/kg/day or 60 mg/day, whichever is less.[51735] [53675] [53676] In older adolescents, 10 to 30 mg/dose PO every 6 to 8 hours may be given.[53680]

Neonates

0.5 to 1 mg/kg/day PO divided every 6 to 8 hours, initially. Increase the dose by 1 mg/kg/day every 3 to 5 days as needed for clinical effect. Usual dose: 2 to 4 mg/kg/day. Max: 16 mg/kg/day or 60 mg/day, whichever is less.[51735] [53675] [53676]

Oral dosage (extended-release)†

Adults

60 mg PO once daily, initially. Adjust dose as needed based on response. Max: 160 mg/day.[65743]

For the treatment of an evolving acute myocardial infarction

NOTE: For ST-elevation myocardial infarction, oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have signs of cardiac failure, evidence of low output, increased risk for cardiogenic shock, or other contraindications for beta-blocker therapy.[50429]

Intravenous dosage

Adults

0.1 mg/kg IV, administered in 3 equal divided doses at 2 to 3 minute intervals.

Oral dosage (immediate-release formulations)

Adults

180 to 320 mg/day PO, given in 3 to 4 divided doses.

For reduction of cardiovascular mortality in stable patients who have sustained a myocardial infarction

Oral dosage (immediate-release formulations)

Adults

180 to 240 mg/day PO, given in 3 to 4 divided doses starting in the first 24 hours post-MI.[28271] [50429]

For the treatment of hypertension

Oral dosage (immediate-release formulations)

Adults

Initially, 40 mg PO twice daily, then increase at 3 to 7 day intervals up to 160 to 480 mg/day, given in 2 to 3 divided doses. Max: 640 mg/day. In geriatric patients, begin with conservative initial doses and titrate carefully; the elderly have unpredictable responses to beta-blockers.

Children† and Adolescents†

Initially, 0.5 to 2 mg/kg/day PO in 2 to 4 divided doses. Titrate gradually every 3 to 7 days as needed for clinical effect; heart rate may be dose-limiting. Usual effective dosage is 1 to 6 mg/kg/day. Max: 8 mg/kg/day or 640 mg/day, whichever is less..[32337] [42868] [53585] [53686] [53687] [53688]

Neonates† and Infants†

Initially, 0.25 mg/kg/dose PO every 6 to 8 hours. Titrate gradually as needed for clinical effect; heart rate may be dose-limiting. Max: 3.5 mg/kg/dose; others recommend a max of 5 mg/kg/day.[53681] [53682]

Oral dosage (extended-release capsules except InnoPran XL)

Adults

Initially, 80 mg PO once daily. Increase dosage at 3 to 7 day intervals up to 120 to 160 mg PO once daily. Max: 640 mg/day. In geriatric patients, begin with conservative initial doses and titrate carefully; the elderly have unpredictable responses to beta-blockers.

Oral dosage (InnoPran XL extended-release capsules only)

Adults

Initially, 80 mg PO once daily at bedtime (approximately 10 PM). If needed, increase dosage to 120 mg PO once daily at bedtime. Max: 120 mg/day. In geriatric patients, begin with conservative initial doses and titrate carefully; the elderly have unpredictable responses to beta-blockers.

Continuous IV infusion dosage† (for patients unable to tolerate oral therapy)

Adults

Limited data suggest a continuous infusion of propranolol may be effective in post-surgical patients who cannot tolerate oral therapy. An infusion rate of 2 to 3 mg/hour achieved therapeutic propranolol serum levels within 3 hours. Continuous infusions were administered for up to 9 days.[33684] [33685]

Intermittent intravenous dosage†

Neonates†

0.01 mg/kg/dose slow IV push over 10 minutes, repeated every 6 to 8 hours as needed. Titrate gradually as needed for clinical effect; heart rate may be dose-limiting. Max: 0.15 mg/kg/dose.[53681] [53682]

For the treatment of idiopathic hypertrophic subaortic stenosis (IHSS)

Oral dosage (immediate-release tablets or oral solution)

Adults

20 to 40 mg PO 3 or 4 times daily. For geriatric patients, begin with low initial doses, followed by careful dosage titration; geriatric patients have unpredictable responses to beta-blockers.

Oral dosage (extended-release capsules)

Adults

80 to 160 mg PO once daily. For geriatric patients, begin with low initial doses, followed by careful dosage titration; geriatric patients have unpredictable responses to beta-blockers.

For management of pheochromocytoma, including preoperative control of tachycardia before surgery, in conjunction with an alpha-blocker

Oral dosage (immediate-release tablets or oral solution)

Adults

The usual dosage is 60 mg/day PO, given in divided doses for 3 days before surgery, in conjunction with an alpha-blocker. For the management of inoperable tumors, the usual dosage is 30 mg daily in divided doses as adjunctive therapy to alpha-adrenergic blockade. For geriatric patients, begin with low initial doses, followed by careful dosage titration; the elderly have unpredictable responses to beta-blockers.

For migraine prophylaxis

for migraine prophylaxis in adults

Oral dosage (immediate-release tablets or oral solution)

Adults

80 mg/day PO in divided doses, initially. May increase the dose gradually as needed. Usual dose: 160 to 240 mg/day in divided doses. Discontinue if adequate results not achieved within 4 to 6 weeks.[28271] [53585] Guidelines classify propranolol as having established efficacy for migraine prophylaxis.[57981] [69288]

Oral dosage (extended-release capsules)

Adults

80 mg PO once daily, initially. May increase the dose gradually as needed. Usual dose: 160 to 240 mg/day. Discontinue if adequate results not achieved within 4 to 6 weeks.[53617] Guidelines classify propranolol as having established efficacy for migraine prophylaxis.[57981] [69288]

for migraine prophylaxis in pediatric patients†

Oral dosage (immediate-release tablets or oral solution)

Children and Adolescents weighing more than 35 kg

0.6 to 3 mg/kg/day PO in 2 to 3 divided doses. Max: 120 mg/day.[33312] [53692] [53693] [53694] [53695] [53696] Pediatric patients receiving propranolol are possibly more likely than those receiving placebo to have at least a 50% reduction in headache frequency.[64586]

Children and Adolescents weighing 35 kg or less

0.6 to 3 mg/kg/day PO in 2 to 3 divided doses. Max: 60 mg/day.[33312] [53692] [53693] [53694] [53695] [53696] Pediatric patients receiving propranolol are possibly more likely than those receiving placebo to have at least a 50% reduction in headache frequency.[64586]

For the management of tremor

for the management of essential tremor

Oral dosage (immediate-release tablets or oral solution)

Adults

40 mg PO twice daily. Increase dose as needed to 120 to 320 mg/day PO given in 2 to 3 divided doses. In geriatric patients, begin with conservative initial doses and titrate carefully; geriatric patients have unpredictable responses to beta-blockers.[28271] Clinical practice guidelines consider propranolol effective for the treatment of essential tremor.[58395]

for the management of essential tremor in pediatric patients

Oral dosage (immediate-release formulations)

Adolescents†

Limited experience; dosage often not reported in the literature; efficacy rate of 50%, along with side effect profile may lead to pursuit of other treatment options. 0.5 to 1 mg/kg/day PO, given in 3 divided doses has been recommended by some experts as an initial dose. Titrate dosage gradually once weekly. Alternatively, 30 mg PO once daily, then increased to 30 mg PO twice daily has been effective in improving hand tremor. Many patients respond to a total daily dosage of 60 to 80 mg/day PO. Max: 4 mg/kg/day PO. Dosage may also be taken as needed 30 minutes prior to activities disrupted by essential tremor. Pharmacotherapy should be reserved for patients whose tremor is functionally or socially limiting. Once an optimal dosage is determined, patients may transition to an extended-release formulation of propranolol, to be given once daily. Many patients require larger doses after 1 year of therapy, due to drug tolerance and disease progression.[53697] [53698]

Children†

Limited experience; dosage often not reported in the literature; efficacy rate of 50%, along with side effect profile may lead to pursuit of other treatment options. 0.5 to 1 mg/kg/day PO, given in 3 divided doses has been recommended by some experts as an initial dose using immediate release dose forms. Titrate dosage gradually once weekly as necessary; many patients respond to a total daily dosage of 60 to 80 mg/day PO. Max: 4 mg/kg/day PO. Dosage may also be taken as needed 30 minutes prior to activities disrupted by essential tremor. Pharmacotherapy should be reserved for patients whose tremor is functionally or socially limiting; most do not require therapy until adolescence. Once an optimal dosage is determined, patients may transition to an extended-release formulation of propranolol, to be given once daily. Many patients require larger doses after 1 year of therapy, due to drug tolerance and disease progression.[53697] [53698]

for the management of lithium-induced tremor†

Oral dosage

Adults

Limited data suggest 30 to 80 mg/day PO may be effective; the daily dose is divided into 3 or 4 doses for administration. A common starting dose is 10 mg PO 3 times daily. In a single-blind crossover comparison of propranolol and placebo in 10 patients with lithium-induced tremor, propranolol (30 to 80 mg/day PO) and placebo were administered during two 2-week periods, 1 week on propranolol and 1 on placebo in random order. In period 1, 8 patients reported a preference for propranolol over placebo and 5 patients in period 2 reported a preference for propranolol. Treatment with propranolol resulted in a reduction in the intensity of tremor from very troublesome or somewhat troublesome to noticeable but not troublesome or not present. No adverse reactions were reported with propranolol treatment.[43172] In a case report of 5 patients with lithium-induced tremor, treatment with propranolol 30 to 40 mg/day PO, in 3 or 4 divided doses, resulted in control of the tremor. Recurrence of the tremor was reported in 3 of the cases when propranolol therapy was discontinued.[43176] In geriatric patients, begin with conservative initial doses and titrate carefully; geriatric patients have unpredictable responses to beta-blockers.

For the treatment of anxiety† or panic attacks†

Oral dosage (immediate-release tablets or oral solution)

Adults

10 to 80 mg PO, given 1 hour prior to the anxiety-producing event. For geriatric patients, begin with low initial doses, followed by careful dosage titration; geriatric patients have unpredictable responses to beta-blockers.

For the treatment of thyrotoxicosis† and thyroid storm†

for the treatment thyrotoxicosis† in adults

Oral dosage (immediate-release)

Adults

10 to 40 mg PO every 6 to 8 hours.[61515] [64934] [68190]

for the treatment of thyroid storm† in adults

Oral dosage (immediate-release)

Adults

60 to 80 mg PO every 4 hours.[61515]

Intravenous dosage

Adults

1 to 2 mg IV every 15 minutes up to 10 mg.[68189] [68190]

for the treatment of thyrotoxicosis† and thyroid storm† in pediatric patients

Oral dosage (immediate-release)

Adolescents

10 to 40 mg PO every 6 to 8 hours.[53789] [64934]

Children

2 mg/kg/day PO divided every 6 to 12 hours (Max: 40 mg/dose); occasionally higher doses are required.[64934] Flat doses of 20 to 40 mg PO every 6 to 8 hours have been used to treat older children with thyroid storm.[53789] [53790]

Infants

1 to 2 mg/kg/day PO divided doses every 6 to 12 hours; occasionally higher doses are required.[53710] [53711] [53712] [53713] [53714] [53785] [53786] [53787] [64934]

Neonates

1 to 2 mg/kg/day PO divided doses every 6 to 12 hours; occasionally higher doses are required.[53710] [53711] [53712] [53713] [53714] [53785] [53786] [53787] [64934]

Intravenous dosage

Children and Adolescents

1 to 3 mg IV as a single dose.[53789] [53790]

For the treatment of hypertension and the subsequent decline in renal function associated with scleroderma renal crisis (SRC)†

Oral dosage (immediate-release tablets or oral solution)

Adults

Initially, 40 mg PO twice daily, then increase at 3 to 7 day intervals up to 160 to 480 mg/day PO to attain desired blood pressure response. For geriatric patients, begin with low initial doses, followed by careful dosage titration; geriatric patients have unpredictable responses to beta-blockers.

For variceal bleeding prophylaxis† in persons with esophageal varices

Oral dosage (immediate-release)

Adults

20 to 40 mg PO twice daily, initially. Increase the dose every 2 to 3 days until resting heart rate of 55 to 60 beats per minute with systolic blood pressure of 90 mmHg or more. Max: 320 mg/day in persons without ascites; 160 mg/day in persons with ascites. A non-selective beta-blocker, including propranolol, or endoscopic variceal ligation (EVL) is recommended to prevent first variceal hemorrhage (primary prophylaxis) in persons with medium/large esophageal varices or high-risk small esophageal varices, and the combination of propranolol plus EVL is recommended in the prevention of rebleeding (secondary prophylaxis).[64335]

For the treatment of chronic agitation† or aggressive behavior

Oral dosage (immediate-release tablets or oral solution)

Adults

Most of the literature describing positive outcomes in the treatment of chronic aggression with propranolol involved patients with co-existing organic brain disease or schizophrenia recalcitrant to other aggression modalities. For patients without preexisting cardiovascular disorders, some authors have suggested a beginning dose of 20 mg PO 3 times per day, increasing the total dose by 40 to 60 mg/day every 3 days. Mean dosages range from 160 to 320 mg/day.[24581] For geriatric patients, begin with low initial doses, followed by careful dosage titration; geriatric patients have unpredictable responses to beta-blockers.

For the prevention and treatment of hypercyanotic episodes associated with tetralogy of Fallot (i.e., tetralogy spells†)

Oral dosage (immediate-release)

Infants and Children

1 mg/kg/day PO divided every 6 hours, initially. After 1 week, may titrate dose by 1 mg/kg/day every 24 hours as necessary. Average dose: 2.3 mg/kg/day (range: 0.8 to 5 mg/kg/day). Usual Max: 5 mg/kg/day. If the patient becomes refractory after initial control, may increase dose gradually to a maximum of 10 to 15 mg/kg/day; monitor heart size, heart rate, and cardiac contractility closely. Alternatively, 4 mg/kg/day PO divided every 6 hours has been used as an initial dose.[53716] [53717]

Intravenous dosage

Infants and Children

0.15 to 0.25 mg/kg/dose (Max: 1 mg/dose) IV; may repeat once. Alternatively, 0.01 to 0.02 mg/kg/dose IV has been used, reserving higher doses for refractory spells.[32485] [44772]

For the treatment of a proliferating infantile hemangioma requiring systemic therapy

To reduce the risk of hypoglycemia, administer propranolol immediately after or concurrently with a feeding. Avoid fasting; if inevitable, hold medication or support with a product such as Pedialyte or glucose-containing IV fluids.[53721] [56853] Vital signs and cardiorespiratory exam or ECG should be obtained at baseline.[53721] Obtain blood pressure and heart rate measurements at 1 and 2 hours after the initial dose and any significant dose increase (e.g., more than 0.5 mg/kg/day).[53721] [56853] Experts have recommended propranolol therapy continue until full involution of the lesion has occurred or the patient is at least 1 year of age; recurrences have been reported with early discontinuation. At the end of therapy, gradually taper propranolol over 2 to 4 weeks.[53640] [53722] [53723] [53724] [53725] [53726] [63864] If hemangiomas recur, treatment may reinitiated.[56853]

Oral dosage (FDA-approved dosage)

Infants 5 weeks to 5 months at initiation

0.6 mg/kg/dose PO twice daily given at least 9 hours apart. After 1 week of treatment, increase dosage to 1.1 mg/kg/dose PO twice daily. After 2 weeks of treatment, increase dosage to 1.7 mg/kg/dose PO twice daily and maintain this dosage for 6 months. Readjust dosage periodically based on weight increases.[56853]

Neonates and Infants

1 mg/kg/DAY PO initially, titrated to a target dose of 2 to 3 mg/kg/DAY, unless there are comorbidities (e.g., PHACE syndrome, progressive ulceration) or adverse reactions that require a lower dose. Administer in 2 to 3 divided doses; administer 3 times daily to minimize abrupt changes in blood pressure in high risk patients.[53721] [63864] [63885] Infantile hemangiomas often respond rapidly even to low doses of propranolol; dose escalation and optimal target dose should be based on individual patient response. Consensus guideline initiation protocols are based on corrected gestational age, social support status, and patient comorbidities affecting the cardiovascular or respiratory systems, and/or blood glucose maintenance. Inpatient initiation (neonates and infants younger than 8 weeks, inadequate social support, or comorbidities): 0.33 mg/kg/dose PO every 8 hours. If tolerated, increase dose to 0.66 mg/kg/dose PO every 8 hours and prepare for discharge. If the dose is not tolerated at any point in time, reduce the dosage and gradually increase to the target dose; it is recommended patients be discharged on a tolerated dose of at least 1 mg/kg/day. Outpatient initiation (infants older than 8 weeks and adequate social support): 0.33 mg/kg/dose PO given 3 times daily at least 6 hours apart. If tolerated for 3 to 7 days, increase dose to 0.5 mg/kg/dose PO given 3 times daily. If once again tolerated for 3 to 7 days, increase dose to 0.66 mg/kg/dose PO given 3 times daily. If the dose is not tolerated at any point in time, reduce the dosage and gradually increase to the target dose; consider a target dose of 1 mg/kg/day.[53721]

For the attenuation of hypermetabolism in patients with severe burns†

for the attenuation of hypermetabolism in adult patients with severe burns

Oral dosage (immediate-release formulations)

Adults

1 mg/kg/day PO, given in divided doses every 4 hours. Adjust dose as needed to achieve a target 20% reduction in heart rate from baseline to a maximum dose of 1.98 mg/kg/day. Median dose: 80 mg/day.[57432]

for the attenuation of hypermetabolism in pediatric patients with severe burns

Oral dosage (immediate-release formulations)

Infants, Children, and Adolescents

1 to 4 mg/kg/day PO, given in divided doses every 6 hours. Adjust dose as needed to decrease heart rate by 10% to 20% of the admission value or mean age-based population value. 4 mg/kg/day PO was the mean effective dose in an interim analysis of children (n = 90; mean age 7 +/- 5 years) with more than 30% total body surface area burns. Propranolol therapy began 96 hours postburn and continued for 1 year with few adverse effects. Propranolol therapy significantly reduced heart rate and resting energy expenditure, decreased truncal fat accumulation, prevented bone loss, and improved lean body mass accretion. Maximum dose not clearly defined; severely burned adult patients standardly receive 20 mg PO every 6 hours, with dosage titrated as needed.[53802] [53803] [53804]

For the treatment of heart failure† (ischemic origin or cardiomyopathy†) usually in conjunction with digoxin, diuretics, or ACE inhibitor therapy in children and infants

Oral dosage (immediate-release formulations)

Infants and Children

Initially, 0.5 to 1 mg/kg/day PO, given in divided doses every 6 to 8 hours has been recommended for sympathetic inhibition. Titrate dosage gradually every 3 to 14 days to a target dose of 2 mg/kg/day PO (range: 1.5 to 3 mg/kg/day). Monitor heart rate and blood pressure.[53738] [53739] [53740]

For the treatment of premature ventricular contractions (PVCs)†

Oral dosage (immediate-release)

Adults

10 to 40 mg PO every 6 hours.[65747] [68764]

Oral dosage (extended-release)

Adults

60 to 160 mg PO every 12 hours.[65747] [68764]

Intravenous dosage

Adults

1 to 3 mg IV every 5 minutes as needed up to a total of 5 mg.[65747]

Therapeutic Drug Monitoring

Maximum Dosage Limits

  • Adults

    160 mg/day PO for idiopathic hypertrophic subaortic stenosis (IHSS); 240 mg/day PO for migraine prophylaxis, myocardial infarction prophylaxis, or post-myocardial infarction; 320 mg/day PO for angina, paroxysmal supraventricular tachycardia (PSVT), or tremor; 640 mg/day PO for hypertension. NOTE: Assumes equivalent maximum daily dosage for immediate-release and extended-release products.

  • Geriatric

    160 mg/day PO for idiopathic hypertrophic subaortic stenosis (IHSS); 240 mg/day PO for migraine prophylaxis, myocardial infarction prophylaxis, or post-myocardial infarction; 320 mg/day PO for angina, paroxysmal supraventricular tachycardia (PSVT), or tremor; 640 mg/day PO for hypertension. NOTE: Assumes equivalent maximum daily dosage for immediate-release and extended-release products.

  • Adolescents

    Safety and efficacy have not been established; the dose required is dependent on route of administration, indication, and often clinical response. For tachyarrhythmias, doses up to 60 mg/day PO (or 120 mg/day PO in older adolescents) or 0.25 mg/kg/dose IV (Max: 3 mg/dose) have been used. For hypertension, doses up to 8 mg/kg/day PO (Max: 640 mg/day) have been used. For migraine prophylaxis, doses up to 120 mg/day PO have been used. For essential tremor, doses up to 4 mg/kg/day PO have been used.

  • Children

    Children weighing more than 35 kg: Safety and efficacy have not been established; the dose required is dependent on route of administration, indication, and often clinical response. For tachyarrhythmias, doses up to 60 mg/day PO or 0.25 mg/kg/dose IV (Max: 3 mg/dose) have been used. For hypertension, doses up to 8 mg/kg/day PO (Max: 640 mg/day) have been used. For migraine prophylaxis, doses up to 120 mg/day PO have been used. For essential tremor, doses up to 4 mg/kg/day PO have been used. For tetralogy spells, doses up to 15 mg/kg/day PO have been used (doses more than 5 mg/kg/day PO require close monitoring).

    Children weighing 35 kg or less: Safety and efficacy have not been established; the dose required is dependent on route of administration, indication, and often clinical response. For tachyarrhythmias, doses up to 60 mg/day PO or 0.25 mg/kg/dose IV (Max: 3 mg/dose) have been used. For hypertension, doses up to 8 mg/kg/day PO (Max: 640 mg/day) have been used. For migraine prophylaxis, doses up to 60 mg/day PO have been used. For essential tremor, doses up to 4 mg/kg/day PO have been used. For tetralogy spells, doses up to 15 mg/kg/day PO have been used (doses more than 5 mg/kg/day PO require close monitoring).

  • Infants

    3.4 mg/kg/day PO for infantile hemangiomas. Safety and efficacy for other indications have not been established; the dose required is dependent on route of administration, indication, and often clinical response. For tachyarrhythmias, doses up to 16 mg/kg/day PO (Max: 60 mg/day) or 0.15 mg/kg/dose IV (Max: 1 mg/dose) have been used. For hypertension, doses up to 3.5 mg/kg/dose PO have been used. For tetralogy spells, doses up to 15 mg/kg/day PO have been used (doses more than 5 mg/kg/day PO require close monitoring).

  • Neonates

    Safety and efficacy have not been established; the dose required is dependent on route of administration, indication, and often clinical response. For tachyarrhythmias, doses up to 16 mg/kg/day PO (Max: 60 mg/day) or 0.15 mg/kg/dose IV (Max: 1 mg/dose) have been used. For hypertension, doses up to 3.5 mg/kg/dose PO or 0.15 mg/kg/dose IV have been used.

Patients with Hepatic Impairment Dosing

Since propranolol is primarily metabolized by the liver, initiate therapy at a reduced dosage for the specified indication; carefully titrate the dosage to attain the desired clinical goals.

Patients with Renal Impairment Dosing

No dosage adjustment needed.

 

Intermittent hemodialysis

No dosage adjustments are needed; propranolol is not significantly dialyzable.[40143]

† Off-label indication
Revision Date: 08/12/2023, 07:40:06 PM

References

23966 - Braunwald E, Mark DB, Jones RH, et al. Unstable angina: diagnosis and management. Clinical Practice Guideline No. 10. AHCPR Publication no. 94-0602. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1994.24581 - Pabis DJ, Stanislav SW. Pharmacotherapy of aggressive behavior. Ann Pharmacother 1996;30:278-87.28271 - Propranolol tablet package insert. Parsippany, NJ: Actavis Pharma, Inc.; 2015 Aug.32337 - Robinson RF, Nahata MC, Batisky DL, et al. Pharmacologic treatment of chronic pediatric hypertension. Paediatr Drugs 2005;7:27-40.32485 - American Academy of Pediatrics Committee on Drugs. Drugs for pediatric emergencies. Pediatrics 1998;101(1):e1333312 - Lewis D, Ashwall S, Hershey A, et al. Practice parameter: pharmacological treatment of migraine headache in children and adolescents; report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology 2004;63:2215-24.33684 - Smulyan H, Weinberg SE, Howanitz PJ. Continuous propranolol infusion following abdominal surgery. JAMA 1982;247:2539-42.33685 - Hug CC, McDonald DH, Kaplan JA. Propranolol infusions after abdominal surgery. JAMA 1983;249:22.40143 - Innopran XL (propranolol hydrochloride) package insert. Baudette, MN: ANI Pharmaceuticals, Inc.; 2023 Dec.42868 - National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114:555-7643172 - Kirk L, Baastrup PC, Schou M. Propranolol treatment of lithium-induced tremor. Lancet 1973;2:1086-7.43176 - Lapierre YD. Control of lithium tremor with propranolol. Can Med Assoc J 1976;114:619-24.44772 - Hegenbarth MA. Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008;121:433-43.45870 - Propranolol HCl injection package insert. Berkeley Heights, NJ: Hikma Pharmaceuticals USA Inc; 2022 May.50429 - Antman EM, Hand M, et al. 2007 Focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. Circulation 2008;117:296-329.51735 - Escudero C, Carr R, Sanatani S. The medical management of pediatric arrhythmias. Curr Treat Options Cardiovasc Med 2012;14:455-72.53585 - propranolol oral solution package insert. Columbus, OH:Boehringer Ingelheim Roxane Laboratories; 2012 Jan.53617 - Inderal LA (propranolol sustained-release) capsules. Baudette, MN: ANI Pharmaceuticals, Inc. 2023 Nov.53640 - Lawley LP, Siegfried E, Todd JL. Propranolol treatment for hemangioma of infancy: risks and recommendations. Pediatr Derm 2009;26:610-614.53675 - Pickoff AS, Zies L, Ferrer PL. High-dose propranolol therapy in the management of supraventricular tachycardia. J Pediatr 1979;94:144-146.53676 - Gillette P, Garson A, Eterovic E. Oral propranolol treatment in infants and children. J Pediatr 1978;92:141-144.53680 - Bar-Cohen Y, Silka MJ. Management of postoperative arrhythmias in pediatric patients. Curr Treat Options Cardiovasc Med 2012;14:443-454.53681 - Ong WH, Guignard JP, Sharma A. Pharmacological approach to the management of neonatal hypertension. Semin Neonatal 1998;3:149-163.53682 - Rasoulpour M, Marinelli KA. Systemic hypertension. Clin Perinatol 1992;19:121-137.53686 - Blowey DL. Antihypertensive agents: mechanisms of action, safety profiles, and current uses in children. Curr Ther Res Clin Exp 2001;62:298-313.53687 - Sinaiko AR. Pharmacologic management of childhood hypertension. Ped Clin North Amer 1993;40:195-212.53688 - Griswold WR, McNeal R, Medoza SA. Propranolol as an antihypertensive agent in children. Arch Dis Child 1978;53:594-596.53692 - Ludvigsson J. Propranolol used in prophylaxis of migraine in children. Acta Neurol Scandinav 1974;50:109-115.53693 - Lai CW, Ziegler DK, Lansky LL. Hemiplegic migraine in childhood: diagnostic and therapeutic aspects. J Pediatr 1982;101:696-699.53694 - Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Pediatrics 1987;79:593-597.53695 - Ashrafi MR, Shabanian R, Zamani GR, et al. Sodium valproate versus propranolol in paediatric migraine prophylaxis. Eur J Paediatr Neurol 2005;9:333-338.53696 - Bidabadi E, Mashouf M. A randomized trial of propranolol versus sodium valproate for the prophylaxis of migraine in pediatric patients. Pediatr Drugs 2010;12:269-275.53697 - Ferrara J, Jankovic J. Epidemiology and management of essential tremor in children. Pediatr Drugs 2009;11:293-307.53698 - Keller S, Dure LS. Tremor in childhood. Sem Pediatr Neurol 2009;16:60-70.53710 - Peter F, Muzsnai A. Congenital disorders of the thyroid: hypo/hyper. Pediatr Clin North Am 2011;38:1099-1115.53711 - Mustafa MS, Betts PR. Neonatal thyrotoxicosis. Curr Paediatr 1997;7:88-91.53712 - Smith CS, Howard NJ. Propranolol in treatment of neonatal thyrotoxicosis. J Pediatr 1973;1046-1048.53713 - Gilani B, Mattimore J, Menon V. Propranolol treatment of neonatal thyrotoxicosis. Am J Dis Child 1981;135:290.53714 - Gardner LI. Is propranolol alone really beneficial in neonatal thyrotoxicosis: bradycardia and hypoglycemia evoke the doctrine of primum non nocere. Am J Dis Child 1980;134:819-820.53716 - Garson A, Gillette PC, McNamara DG. Propranolol: the preferred palliation for tetralogy of fallot. Am J Cardiol 1981;47:1098-1104.53717 - Ponce FE, Williams LC, Webb HM. Propranolol palliation of tetralogy of fallot: experience with long-term drug treatment in pediatric patients. Pediatrics 1973;52:100-108.53721 - Drolet BA, Frommelt PC, Chamlin SL. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics 2013;131:128-140.53722 - Tan ST, Itinteang T, Leadbitter P. Low-dose propranolol for infantile haemangioma. J Plast Reconstr Aesthet Surg 2011;64:292-300.53723 - Leboulanger N, Fayoux P, Teissier N. Propranolol in the therapeutic strategy of infantile laryngotracheal hemangioma: a preliminary retrospective study of French experience. Int J Pediatr Otorhinolaryngol 2010;74:1254-1257.53724 - Buckmiller LM, Munson PD, Dyamenahalli U. Propranolol for infantile hemangiomas: early experience at a tertiary vascular anomalies center. Laryngoscope 2010;120:676-681.53725 - Vanlander A, Decaluwe W, Vandelanotte M. Propranolol as a novel treatment for congenital visceral haemangioma. Neonatology 2010;98:229-231.53726 - Fay A, Nguyen J, Jakobiec FA. Propranolol for isolated orbital infantile hemangioma. Arch Opthalmol 2010;128:256-258.53734 - Luedtke SA, Kuhn RJ, McCaffrey FM. Pharmacologic management of supraventricular tachycardias in children. Part 2: atrial flutter, atrial fibrillation, and junctional and atrial ectopic tachycardia. Ann Pharmacother 1997;31:1347-1359.53738 - Buchhorn R, Ross RD, Hulpke-Wette M. Effectiveness of low dose captopril versus propranolol therapy in infants with severe congestive failure due to left-to-right shunts. Int J Cardiol 2000;76:227-23353739 - Buchhorn R, Hulpke-Wette M, Hilgers R. Propranolol treatment of congestive heart failure in infants with congenital heart disease: The CHF-PRO-INFANT trial. Int J Cardiol 2001;79:167-173.53740 - Ross RD. Medical management of chronic heart failure in children. Am J Cardiovasc Drugs 2001;1:37-44.53785 - Smith C, Thomsett M, Choong C. Congenital thyrotoxicosis in premature infants. Clin Endocrinol 2001;54:371-376.53786 - Peters CJ, Hindmarsh PC. Management of neonatal endocrinopathies--best practice guidelines. Early Hum Dev 2007;83:553-561.53787 - Pemberton PJ, McConnell B, Shanks RG. Neonatal thyrotoxicosis treated with propranolol. Arch Dis Child 1974;49:813-815.53789 - Lee HS, Hwang JS. Seizure and encephalopathy associated with thyroid storm in children. J Child Neurol 2011;26:526-528.53790 - Galaburda M, Rosman P, Haddow JE. Thyroid storm in an 11-year-old boy managed by propranolol. Pediatrics 1974;53:920-922.53802 - Herndon DN, Rodriguez NA, Diaz EC. Long-term propranolol use in severely burned pediatric patients. Ann Surg 2012;256:402-411.53803 - Williams FN, Herndon DN, Kulp GA. Propranolol decreases cardiac work in a dose-dependent manner in severely burned children. Surgery 2011;149:231-239.53804 - Rojas Y, Finnerty CC, Radhakrishnan RS. Burns: an update on current pharmacotherapy. Expert Opin Pharmacother 2012;13:2485-2494.56853 - Hemangeol (propranolol hydrochloride) oral solution package insert. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; 2021 Jun.56966 - January CT, Wann, LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation. J Am Coll Cardiol 2014;64:2305-7.57432 - Mohammadi AA, Bakhshaeekia A, Alibeigi P, et al. Efficacy of propranolol in wound healing for hospitalized burn patients. J Burn Care Res 2009;30:1013-1017.57981 - Silberstein SD, Holland S, Freitag F, et al. Evidence based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Report of the quality standards subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78:1337-1345.58395 - Zesiewicz TA, Elble RJ, Louis ED, et al. Evidence-based guideline update: Treatment of essential tremor: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurol 2011;77:1752-1755.61515 - Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 2016;26:1343-1421.63864 - Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics 2019;143:e20183475.63885 - Hoeger PH, Harper JI, Baselga E, et al. Treatment of infantile haemangiomas: recommendations of a European expert group. Eur J Pediatr 2015;174:855-865.64335 - Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017;65:310-33564586 - Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019;93:500-509.64934 - Shenoi RP, Timm N, AAP Committee on Drugs, AAP Committee on Emergency Medicine. Drugs used to treat pediatric emergencies. Pediatrics 2020;145:e20193450.65743 - Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2016;5:e27-e115.65747 - Al-Khatib SM, Stevenson WG, Ackerman JM, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018;72:e91-e220.65848 - January CT, Wann SL, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2019;140:e125-e151.66054 - Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: Adult Basic and Advanced Cardiovascular Life Support: 2020 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142:S366-S468.68189 - Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun;1:139-45.68190 - Devereaux D, Tewelde SZ. Hyperthyroidism and thyrotoxicosis. Emerg Med Clin North Am. 2014 May;32:277-92.68764 - Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al; ESC Scientific Document Group. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022 Oct 21;43(40):3997-4126.69288 - Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache 2021 ;61:1021-1039.

How Supplied

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 60mg Extended-Release Capsule (00046-0470) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 60mg Extended-Release Capsule (24090-0470) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 60mg Extended-Release Capsule (24090-0470) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 60mg Extended-Release Capsule (62559-0520) (ANI Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 60mg Extended-Release Capsule (00046-0470) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

INDERAL LA 60mg Extended-Release Capsule (62559-0520) (ANI Pharmaceuticals, Inc.) nullINDERAL LA 60mg Extended-Release Capsule package photo

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00258-3609) (Allergan USA, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (68084-0209) (American Health Packaging) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (68084-0503) (American Health Packaging) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (60687-0215) (American Health Packaging) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (43478-0900) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (62559-0530) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (42291-0522) (AvKARE, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (51991-0817) (Breckenridge Inc) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (61919-0488) (Direct Rx) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (60429-0126) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00527-4116) (Lannett Company, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00904-5947) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00378-6160) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00603-5497) (Par Pharmaceuticals, an Endo Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (49884-0282) (Par Pharmaceuticals, an Endo Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (43478-0900) (Rouses Point Pharmaceuticals, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00228-2778) (Teva/Actavis US) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 60mg Extended-Release Capsule (00245-0084) (Upsher-Smith Laboratories, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride Long-Acting 60mg Capsule (59911-5470) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 80mg Extended-Release Capsule (00046-0471) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 80mg Extended-Release Capsule (24090-0471) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 80mg Extended-Release Capsule (24090-0471) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 80mg Extended-Release Capsule (62559-0521) (ANI Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 80mg Extended-Release Capsule (00046-0471) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

INDERAL LA 80mg Extended-Release Capsule (62559-0521) (ANI Pharmaceuticals, Inc.) nullINDERAL LA 80mg Extended-Release Capsule package photo

Propranolol Hydrochloride Oral capsule, extended release

Inderal XL 80mg Extended-Release Capsule (76299-0420) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal XL 80mg Extended-Release Capsule (62559-0600) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal XL 80mg Extended-Release Capsule (76299-0420) (Mist Pharmaceuticals) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 80mg Extended-Release Capsule (00173-0790) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 80mg Extended-Release Capsule (24090-0450) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 80mg Extended-Release Capsule (24090-0450) (ANI Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 80mg Extended-Release Capsule (62559-0590) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 80mg Extended-Release Capsule (00173-0790) (GlaxoSmithKline Group of Companies) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 80mg Extended-Release Capsule (65726-0250) (GlaxoSmithKline Group of Companies ) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (00258-3610) (Allergan USA, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (68084-0210) (American Health Packaging) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (68084-0504) (American Health Packaging) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (60687-0226) (American Health Packaging) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (43478-0901) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (62559-0531) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (42291-0523) (AvKARE, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (10544-0286) (Blenheim Pharmacal, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (51991-0818) (Breckenridge Inc) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (60429-0127) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (00527-4117) (Lannett Company, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (00904-5948) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (00378-6180) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (49884-0328) (Par Pharmaceuticals, an Endo Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (43478-0901) (Rouses Point Pharmaceuticals, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (00228-2779) (Teva/Actavis US) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 80mg Extended-Release Capsule (00245-0085) (Upsher-Smith Laboratories, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride Long-Acting 80mg Capsule (59911-5471) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 120mg Extended-Release Capsule (00046-0473) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 120mg Extended-Release Capsule (24090-0473) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 120mg Extended-Release Capsule (24090-0473) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 120mg Extended-Release Capsule (62559-0522) (ANI Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 120mg Extended-Release Capsule (00046-0473) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

INDERAL LA 120mg Extended-Release Capsule (62559-0522) (ANI Pharmaceuticals, Inc.) nullINDERAL LA 120mg Extended-Release Capsule package photo

Propranolol Hydrochloride Oral capsule, extended release

Inderal XL 120mg Extended-Release Capsule (76299-0422) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal XL 120mg Extended-Release Capsule (62559-0601) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal XL 120mg Extended-Release Capsule (76299-0422) (Mist Pharmaceuticals) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 120mg Extended-Release Capsule (00173-0791) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 120mg Extended-Release Capsule (24090-0451) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 120mg Extended-Release Capsule (24090-0451) (ANI Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 120mg Extended-Release Capsule (62559-0591) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 120mg Extended-Release Capsule (00173-0791) (GlaxoSmithKline Group of Companies) (off market)

Propranolol Hydrochloride Oral capsule, extended release

InnoPran XL 120mg Extended-Release Capsule (65726-0251) (GlaxoSmithKline Group of Companies ) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00258-3611) (Allergan USA, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (68084-0916) (American Health Packaging) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (60687-0237) (American Health Packaging) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (43478-0902) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (62559-0532) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (42291-0524) (AvKARE, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (51991-0819) (Breckenridge Inc) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (60429-0128) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00527-4118) (Lannett Company, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00904-5949) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00378-6220) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (49884-0329) (Par Pharmaceuticals, an Endo Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (43478-0902) (Rouses Point Pharmaceuticals, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00228-2780) (Teva/Actavis US) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00245-0086) (Upsher-Smith Laboratories, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (59911-5473) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 120mg Extended-Release Capsule (00046-5473) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 160mg Extended-Release Capsule (00046-0479) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 160mg Extended-Release Capsule (24090-0479) (Akrimax Pharmaceuticals LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 160mg Extended-Release Capsule (24090-0479) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 160mg Extended-Release Capsule (62559-0523) (ANI Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Inderal LA 160mg Extended-Release Capsule (00046-0479) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral capsule, extended release

INDERAL LA 160mg Extended-Release Capsule (62559-0523) (ANI Pharmaceuticals, Inc.) nullINDERAL LA 160mg Extended-Release Capsule package photo

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (00258-3612) (Allergan USA, Inc.) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (68084-0932) (American Health Packaging) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (43478-0903) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (62559-0533) (ANI Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (42291-0525) (AvKARE, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (51991-0820) (Breckenridge Inc) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (60429-0129) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (00527-4119) (Lannett Company, Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (00904-5950) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (00378-6260) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (49884-0330) (Par Pharmaceuticals, an Endo Company) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (43478-0903) (Rouses Point Pharmaceuticals, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (00228-2781) (Teva/Actavis US) null

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride 160mg Extended-Release Capsule (00245-0087) (Upsher-Smith Laboratories, LLC) (off market)

Propranolol Hydrochloride Oral capsule, extended release

Propranolol Hydrochloride Long-Acting 160mg Capsule (59911-5479) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral solution [Cardiovascular Disease]

Propranolol Hydrochloride 20mg/5mL Solution (00054-3727) (Hikma Pharmaceuticals USA Inc.) nullPropranolol Hydrochloride 20mg/5mL Solution package photo

Propranolol Hydrochloride Oral solution [Cardiovascular Disease]

Propranolol Hydrochloride 20mg/5mL Solution (00054-8764) (Hikma Pharmaceuticals USA Inc.) (off market)

Propranolol Hydrochloride Oral solution [Cardiovascular Disease]

Propranolol Hydrochloride 20mg/5mL Solution (00121-0908) (Pharmaceutical Associates Inc.) nullPropranolol Hydrochloride 20mg/5mL Solution package photo

Propranolol Hydrochloride Oral solution [Cardiovascular Disease]

Propranolol Hydrochloride 40mg/5mL Solution (00054-3730) (Hikma Pharmaceuticals USA Inc.) nullPropranolol Hydrochloride 40mg/5mL Solution package photo

Propranolol Hydrochloride Oral solution [Cardiovascular Disease]

Propranolol Intensol 80mg/ml Solution (00054-3728) (Hikma Pharmaceuticals USA Inc.) (off market)

Propranolol Hydrochloride Oral solution [Hemangioma]

Hemangeol 4.28mg/mL Solution (64370-0375) (Pierre Fabre Pharmaceuticals, Inc) null

Propranolol Hydrochloride Oral tablet

Inderal 10mg Tablet (00046-0421) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (62584-0842) (American Health Packaging) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (60687-0587) (American Health Packaging) nullPropranolol Hydrochloride 10mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (69292-0530) (Amici Pharmaceuticals, LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (69238-2077) (Amneal Pharmaceuticals LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (23155-0110) (Avet Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (50268-0700) (AvPAK; a Division of AvKARE Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (50268-0662) (AvPAK; a Division of AvKARE Inc) nullPropranolol Hydrochloride 10mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (10544-0282) (Blenheim Pharmacal, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (51407-0235) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (50111-0467) (Impax Generics, a division of Impax Laboratories, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00115-1659) (Impax Generics, a division of Impax Laboratories, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00005-3109) (Lederle Pharmaceutical Div American Cyanamid Co) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00904-0411) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00904-6550) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (51079-0277) (Mylan Institutional LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00378-0182) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (16714-0021) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (16714-0021) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00603-5482) (Par Pharmaceuticals, an Endo Company) nullPropranolol Hydrochloride 10mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00364-0756) (Schein Pharmaceutical Inc, an Actavis Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00677-1041) (Sun Pharmaceutical Industries, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00182-1812) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (50111-0467) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00182-1758) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00591-5554) (Teva/Actavis US) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (52544-0305) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (00228-2327) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 10mg Tablet (50053-3109) (Wyeth Research, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Inderal 20mg Tablet (00046-0422) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (62584-0843) (American Health Packaging) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (60687-0306) (American Health Packaging) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (60687-0598) (American Health Packaging) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (69292-0532) (Amici Pharmaceuticals, LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (69238-2078) (Amneal Pharmaceuticals LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (23155-0111) (Avet Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (50268-0701) (AvPAK; a Division of AvKARE Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (50268-0663) (AvPAK; a Division of AvKARE Inc) nullPropranolol Hydrochloride 20mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (10544-0284) (Blenheim Pharmacal, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (51407-0236) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (50111-0468) (Impax Generics, a division of Impax Laboratories, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00115-1660) (Impax Generics, a division of Impax Laboratories, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00904-0412) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00904-6705) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) nullPropranolol Hydrochloride 20mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (51079-0278) (Mylan Institutional LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00378-0183) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (16714-0022) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (16714-0022) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00603-5483) (Par Pharmaceuticals, an Endo Company) nullPropranolol Hydrochloride 20mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (55289-0233) (PD-Rx Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (55289-0233) (PD-Rx Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (72789-0280) (PD-Rx Pharmaceuticals, Inc.) nullPropranolol Hydrochloride 20mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00364-0757) (Schein Pharmaceutical Inc, an Actavis Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00182-1759) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00182-1813) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (50111-0468) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00228-2329) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (00591-5555) (Teva/Actavis US) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 20mg Tablet (52544-0306) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Inderal 40mg Tablet (00046-0424) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (60687-0295) (American Health Packaging) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (60687-0609) (American Health Packaging) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (69292-0534) (Amici Pharmaceuticals, LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (69238-2079) (Amneal Pharmaceuticals LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (23155-0112) (Avet Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (50268-0702) (AvPAK; a Division of AvKARE Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (50268-0664) (AvPAK; a Division of AvKARE Inc) nullPropranolol Hydrochloride 40mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (10544-0285) (Blenheim Pharmacal, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (51407-0237) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (50111-0469) (Impax Generics, a division of Impax Laboratories, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00115-1661) (Impax Generics, a division of Impax Laboratories, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00904-0414) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (51079-0279) (Mylan Institutional LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00378-0184) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (16714-0023) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (16714-0023) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00603-5484) (Par Pharmaceuticals, an Endo Company) nullPropranolol Hydrochloride 40mg Tablet package photo

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (55289-0234) (PD-Rx Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (43063-0615) (PD-Rx Pharmaceuticals, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (43063-0647) (PD-Rx Pharmaceuticals, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00364-0758) (Schein Pharmaceutical Inc, an Actavis Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00182-1814) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (50111-0469) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00182-1760) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (00591-5556) (Teva/Actavis US) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (52544-0307) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 40mg Tablet (50053-3111) (Wyeth Research, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Inderal 60mg Tablet (00046-0426) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (69292-0536) (Amici Pharmaceuticals, LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (69238-2080) (Amneal Pharmaceuticals LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (23155-0113) (Avet Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (51407-0239) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (50111-0470) (Impax Generics, a division of Impax Laboratories, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (00115-1693) (Impax Generics, a division of Impax Laboratories, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (00005-3102) (Lederle Pharmaceutical Div American Cyanamid Co) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (00378-0187) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (16714-0024) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (16714-0024) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (00603-5485) (Par Pharmaceuticals, an Endo Company) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (50111-0470) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (00228-2321) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (52544-0352) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 60mg Tablet (50053-3102) (Wyeth Research, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Inderal 80mg Tablet (00046-0428) (Wyeth Pharmaceuticals Inc, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (69292-0538) (Amici Pharmaceuticals, LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (69238-2081) (Amneal Pharmaceuticals LLC) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (23155-0114) (Avet Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (51407-0238) (Golden State Medical Supply, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (50111-0471) (Impax Generics, a division of Impax Laboratories, Inc.) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00115-1662) (Impax Generics, a division of Impax Laboratories, Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (51079-0280) (Mylan Institutional LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00378-0185) (Mylan Pharmaceuticals Inc.) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (16714-0025) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (16714-0025) (NorthStar Rx LLC) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00603-5486) (Par Pharmaceuticals, an Endo Company) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00364-0760) (Schein Pharmaceutical Inc, an Actavis Company) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00182-1815) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (50111-0471) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00182-1762) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00591-5557) (Teva/Actavis US) null

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (52544-0308) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (00228-2333) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 80mg Tablet (50053-3112) (Wyeth Research, a subsidiary of Pfizer Inc) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 90mg Tablet (50111-0472) (Teva Pharmaceuticals USA) (off market)

Propranolol Hydrochloride Oral tablet

Propranolol Hydrochloride 90mg Tablet (52544-0353) (Teva/Actavis US) (off market)

Propranolol Hydrochloride Solution for injection

Inderal 1mg/ml Solution for Injection (10019-0145) (Baxter Anesthesia/Critical Care) (off market)

Propranolol Hydrochloride Solution for injection

Inderal 1mg/ml Solution for Injection (00046-3265) (Baxter Anesthesia/Critical Care) (off market)Inderal 1mg/ml Solution for Injection package photo

Propranolol Hydrochloride Solution for injection

Propranolol Hydrochloride 1mg/ml Solution for Injection (55390-0003) (Bedford Laboratories, a Hikma Company) (off market)Propranolol Hydrochloride 1mg/ml Solution for Injection package photo

Propranolol Hydrochloride Solution for injection

Propranolol Hydrochloride 1mg/ml Solution for Injection (63323-0604) (Fresenius Kabi AG) null

Propranolol Hydrochloride Solution for injection

Propranolol Hydrochloride 1mg/ml Solution for Injection (00143-9872) (Hikma Pharmaceuticals USA inc.) (off market)

Propranolol Hydrochloride Solution for injection

Propranolol Hydrochloride 1mg/ml Solution for Injection (00781-3777) (Sandoz Inc. a Novartis Company) null

Propranolol Hydrochloride Solution for injection

Propranolol Hydrochloride 1mg/mL Solution for Injection (00143-9872) (Hikma Pharmaceuticals USA inc.) null

Description/Classification

Description

Propranolol is the prototype of the beta-adrenergic receptor antagonists. It is a competitive, nonselective beta-blocker without intrinsic sympathomimetic activity, similar to nadolol. Although propranolol has membrane-stabilizing effects on the action potential, these effects are clinically insignificant except in overdose situations. Propranolol is a racemic compound, with only its l-isomer having any adrenergic blocking activity. The 2007 AHA guidelines for the management of hypertension state beta-blockers should not be used as first-line therapy for the treatment of hypertension, as several comparative clinical trials have shown beta blockers to be inferior to ACE inhibitors, angiotensin-receptor blockers, or calcium channel blockers for preventing both stroke and coronary artery disease complications. These guidelines do, however, recommend the use of beta-blockers for the treatment of hypertension in patients with angina, prior myocardial infarction, or heart failure.[33826] Propranolol was first approved by the FDA in 1967; an  extended-release formulation designed for bedtime-dosing was approved in March 2003. Hemangeol, an oral solution specifically approved for treatment of proliferating infantile hemangiomas, was approved by the FDA in March 2014.

Classifications

  • Cardiovascular System
    • Antihypertensives
      • Beta-blocking Agents Plain and in Combination
        • Non-Selective Beta-Blockers
    • Cardiac Therapy
      • Anti-arrhythmics
        • Anti-arrhythmics, Class II
Revision Date: 03/28/2014, 01:35:34 PM

References

33826 - Rosendorff C, Black HR, Cannon CP, et al. Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease: A Scientific Statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007;115:2761-88.

Administration Information

General Administration Information

For storage information, see the specific product information within the How Supplied section.

Route-Specific Administration

Oral Administration

Oral Solid Formulations

  • Immediate-release tablets: Administer with food.[28271]

  • Sustained-release capsules (e.g., Inderal LA): Administer once daily. Do not crush or chew; swallow whole. If patients are switched from immediate-release tablets to sustained-release capsules, assure desired therapeutic effects are maintained. Substitution should not be simply considered 1:1 as lower plasma concentrations are achieved with the long-acting product. Further titration may be necessary.[53617][53771]

  • Extended-release capsules (e.g., Innopran XL): Administer once daily at bedtime. Do not crush or chew; swallow whole. Take consistently either on an empty stomach or with food.[40143][53771]

Oral Liquid Formulations

Generic Oral Solution (4 mg/mL or 8 mg/mL):

  • Administer with food.[53585]

 

Hemangeol Oral Solution (4.28 mg/mL; for infantile hemangioma):

  • Record the date on the box when the bottle is first opened.
  • Do not shake the bottle before use.
  • Administer during or right after a feeding. Do not administer the dose if the patient is not eating or vomiting.
  • Using an oral syringe, administer the medicine directly into the child's mouth, against the inside of the cheek. If this is not feasible, the solution may be diluted in a small quantity of milk or fruit juice and given immediately.
  • Keep the child in an upright position for a few minutes after giving the dose.
  • Monitor blood pressure and heart rate for 2 hours after the initial dose and after any significant dose increase.
  • Storage: Store the bottle in the box at room temperature and discard 2 months after opening.[56853]

Injectable Administration

  • Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

Intravenous Administration

IV bolus injection:

  • No dilution necessary. If dilution is necessary for accurate dose delivery, the drug may be diluted in 5% Dextrose Injection, 0.9% Sodium Chloride Injection, or Lactated Ringer's Injection.
  • Monitor ECG and central venous pressure during IV administration.[45870]
  • Adults: Administer at a rate not to exceed 1 mg/minute.
  • Children: Administer via slow IV push over 10 minutes; do not exceed a rate of 1 mg/minute.[45870][53790]

 

Continuous IV infusion:

  • Dilute 15 mg in 500 mL 5% Dextrose Injection; may be concentrated to 15 mg propranolol in 250 mL 5% Dextrose Injection for fluid-restricted patients.
  • For adult patients, infuse at a rate of 2 to 3 mg/hour.

Clinical Pharmaceutics Information

From Trissel's 2‚Ñ¢ Clinical Pharmaceutics Database

Propranolol hydrochloride

pH Range
pH 2.8 to 4
ReferencesAnon. Manufacturer's information and labeling. (Package insert).
Osmolality/Osmolarity
Propranolol hydrochloride injection 1 mg/mL is very hypotonic having an osmolality of 12 mOsm/kg.
ReferencesBretschneider H. Osmolalities of commercially supplied drugs often used in anesthesia. Anesth Analg. 1987; 66
Stability
Propranolol hydrochloride injection in intact containers stored as directed by the manufacturer is stable until the labeled expiration date. Propranolol hydrochloride decomposition leads to lower solution pH and discoloration.
ReferencesAnon. Manufacturer's information and labeling. (Package insert).
ReferencesMcEvoy GK (ed). AHFS Drug Information (current edition). Bethesda, MD: American Society of Health-System Pharmacists.
pH Effects
Propranolol hydrochloride is most stable at pH 3; it is rapidly unstable at alkaline pH. Propranolol hydrochloride in solution fluoresces in the pH range of 4 to 5.
ReferencesKwiecien A, Krzek J, Zylewski M. Stability of chosen beta-adrenolytic drugs of different polarity in basic environment. J AOAC Int. 2008; 91
ReferencesMcEvoy GK (ed). AHFS Drug Information (current edition). Bethesda, MD: American Society of Health-System Pharmacists.
Light Exposure
Propranolol hydrochloride should be protected from exposure to light during long-term storage.
ReferencesAnon. Manufacturer's information and labeling. (Package insert).
Freezing
Propranolol hydrochloride should be protected from freezing during storage.
ReferencesAnon. Manufacturer's information and labeling. (Package insert).
Filtration
Cummings et al. reported no loss of propranolol hydrochloride from 0.5 and 20 mcg/mL dilutions in common infusion solutions due to binding to 0.2-micron filters attached to administration sets.
ReferencesCummings DS, Park MK, Howard AB. Compatibility of propranolol hydrochloride injection with intravenous infusion fluids in plastic containers. Am J Hosp Pharm. 1982; 39
Sorption Leaching
Propranolol hydrochloride has been shown not to undergo sorption to polyvinyl chloride (PVC) plastic bags and PVC administration tubing, polyolefin solutions containers, polyethylene tubing, Silastic tubing, cellulose propionate burettes, and polypropylene/polyethylene plastic syringes.
ReferencesCummings DS, Park MK, Howard AB. Compatibility of propranolol hydrochloride injection with intravenous infusion fluids in plastic containers. Am J Hosp Pharm. 1982; 39
ReferencesKowaluk EA, Roberts MA, Blackburn HD, et al. Interactions between drugs and polyvinyl chloride infusion bags. Am J Hosp Pharm. 1981; 38
ReferencesKowaluk EA, Roberts MS, Polack AE. Interactions between drugs and intravenous delivery systems. Am J Hosp Pharm. 1982; 39
Stability Max
Maximum reported stability periods: In D5W- 24 hours at room temperature. In LR- 24 hours at room temperature. In NS- 24 hours at room temperature.
ReferencesCummings DS, Park MK, Howard AB. Compatibility of propranolol hydrochloride injection with intravenous infusion fluids in plastic containers. Am J Hosp Pharm. 1982; 39
Revision Date: 02/13/2020, 02:48:49 PMCopyright 2004-2024 by Lawrence A. Trissel. All Rights Reserved.

References

28271 - Propranolol tablet package insert. Parsippany, NJ: Actavis Pharma, Inc.; 2015 Aug.40143 - Innopran XL (propranolol hydrochloride) package insert. Baudette, MN: ANI Pharmaceuticals, Inc.; 2023 Dec.45870 - Propranolol HCl injection package insert. Berkeley Heights, NJ: Hikma Pharmaceuticals USA Inc; 2022 May.53585 - propranolol oral solution package insert. Columbus, OH:Boehringer Ingelheim Roxane Laboratories; 2012 Jan.53617 - Inderal LA (propranolol sustained-release) capsules. Baudette, MN: ANI Pharmaceuticals, Inc. 2023 Nov.53771 - Mitchell JF. Institute for Safe Medication Practices: Oral dosage forms that should not be crushed. 2013 Apr. Available on the World Wide Web at: http://www.ismp.org/tools/donotcrush.pdf53790 - Galaburda M, Rosman P, Haddow JE. Thyroid storm in an 11-year-old boy managed by propranolol. Pediatrics 1974;53:920-922.56853 - Hemangeol (propranolol hydrochloride) oral solution package insert. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; 2021 Jun.

Adverse Reactions

Mild

  • abdominal pain
  • agitation
  • alopecia
  • anorexia
  • cough
  • diaphoresis
  • diarrhea
  • dizziness
  • drowsiness
  • emotional lability
  • fatigue
  • fever
  • headache
  • infection
  • insomnia
  • irritability
  • lethargy
  • nausea
  • nightmares
  • paresthesias
  • Peyronie's disease
  • pharyngitis
  • pruritus
  • tremor
  • urticaria
  • vomiting
  • weakness
  • xerophthalmia
  • xerosis

Severe

  • agranulocytosis
  • anaphylactoid reactions
  • AV block
  • bradycardia
  • bronchospasm
  • coma
  • erythema multiforme
  • exfoliative dermatitis
  • heart failure
  • hyperkalemia
  • laryngospasm
  • lupus-like symptoms
  • seizures
  • Stevens-Johnson syndrome
  • thrombosis
  • thrombotic thrombocytopenic purpura (TTP)
  • toxic epidermal necrolysis
  • visual impairment

Moderate

  • colitis
  • confusion
  • constipation
  • depression
  • diabetes mellitus
  • dyspnea
  • elevated hepatic enzymes
  • hallucinations
  • hyperglycemia
  • hypertension
  • hypertriglyceridemia
  • hypoglycemia
  • hypotension
  • impotence (erectile dysfunction)
  • memory impairment
  • myopathy
  • palpitations
  • penile fibrosis
  • psoriaform rash
  • psoriasis
  • sinus tachycardia
  • withdrawal

Most adverse effects of propranolol are manifestations of its therapeutic effect. Sinus bradycardia and hypotension are rarely serious and can be reversed with IV atropine if necessary. AV block, secondary to depressed conduction at the AV node, may necessitate sympathomimetic and/or pressor therapy or use of a temporary pacemaker. Paresthesias of the hands and arterial insufficiency, usually of the Raynaud type, also have been reported.[28271] Peripheral coldness was reported in 7% to 8% of infants during infantile hemangioma clinical trials.[56853]

Heart failure has been reported with the use of propranolol.[28271] Congestive heart failure is more likely to occur in patients with preexisting left ventricular dysfunction and usually will respond to discontinuation of propranolol therapy. Elevations of blood urea nitrogen also have been reported in patients with severe heart failure who are taking propranolol.

Dizziness was reported in 4% to 7% and fatigue in 5% to 7% of patients with hypertension who received propranolol extended-release capsules in clinical trials.[40143] Additional adverse CNS effects reported with propranolol therapy include lethargy, weakness, catatonia, an acute reversible syndrome characterized by disorientation to time and place, visual impairment (reported as visual disturbances), hallucinations, short-term memory impairment, emotional lability, slightly clouded sensorium (e.g., confusion), vivid dreams (e.g., nightmares), decreased performance on neuropsychometrics, and depression manifested by insomnia. With immediate-release formulations, fatigue, lethargy, and vivid dreams appear to be dose-related.[28271] During clinical trials of propranolol oral solution for infantile hemangioma, unspecified sleep disorders (16% to 17.5%), nightmares, (2% to 6%), agitation (4.5% to 8.5%), irritability (1% to 5.5%), and drowsiness (0.9% to 5%) were among the most common adverse events.[56853] [69076]

Gastrointestinal adverse effects reported with propranolol use include nausea, vomiting, diarrhea, constipation, abdominal pain (cramping), epigastric distress, mesenteric arterial thrombosis, and ischemic colitis.[28271] During clinical trials of propranolol oral solution for infantile hemangioma, diarrhea (4.5% to 6%), anorexia (2.5% to 3.5%), abdominal pain (0.5% to 3.5%), and vomiting were commonly reported.[56853]

Patients with preexisting bronchospastic disease are at high risk for exacerbation of asthma, dyspnea, or bronchospasm when treated with propranolol. Bronchospasm has been reported coincident with propranolol therapy in pediatric patients.[28271] During infantile hemangioma clinical trials, aggravated respiratory tract infection such as bronchitis (8% to 13%) and bronchiolitis associated with cough and a febrile response were among the most frequently reported adverse events. In the event of a lower respiratory tract infection associated with dyspnea and wheezing, propranolol therapy should be interrupted if the clinical condition allows (e.g. migraine prophylaxis, treatment for hemangioma).[56853]

Beta-blockers may inhibit catecholamine-induced glycogenolysis, gluconeogenesis, and lipolysis, predisposing to hypoglycemia.[53721] [67279] Additionally, beta-blockers can also mask signs of hypoglycemia (e.g., tachycardia) and increase the risk for severe or prolonged hypoglycemia at any time during treatment.[53617] Hypoglycemia may present in the form of seizures, lethargy, or coma.[56853] Persons should be instructed to seek emergency treatment if severe hypoglycemia occurs.[53617] To reduce the risk of hypoglycemia in pediatric patients, administer propranolol shortly before or after feeds and maintain a consistent feeding schedule. Carefully monitor vital signs and blood glucose concentration during drug initiation and dosage escalation. Advise caregivers with special instructions for dosage adjustment or discontinuation during intercurrent illness (if clinical condition allows) and alternative dietary recommendations.[53721] [56853] Beta-blockers can also occasionally cause hyperglycemia. This is thought to be due to blockade of beta-2-receptors on pancreatic islet cells, which inhibit insulin secretion.[30575] [67279] In addition to acute blood glucose effects, beta-blockers have been shown to increase the risk of developing diabetes mellitus in adult hypertensive patients; evaluate this risk relative to the proven benefits of beta-blockers in reducing cardiovascular events.[26823] [67279] [67280]

Some beta-blockers have been shown to cause hypertriglyceridemia and decrease plasma HDL levels during therapy. The clinical implications of these effects, in light of other cardiovascular advantages of beta-blocker therapy, are not known.[24483] Hypertriglyceridemia is not reported as and adverse effect by the manufacturer of propranolol.[28271]

Propranolol therapy has been associated with isolated reports of exacerbation of myopathy and myotonia. Use caution in patients with pre-existing skeletal muscle disease.[40143]

In hypertensive patients, propranolol has been associated with hyperkalemia and elevated hepatic enzymes (e.g., serum transaminases and alkaline phosphatase).[28271]

Male impotence (erectile dysfunction) has been reported with various beta-blocker therapies, including propranolol. Peyronie's disease (an abnormal curvature of the penis during erection with penile fibrosis) has also been reported with propranolol, but is considered to be very rare.[28271] [40143]

Rare but severe hematologic side effects, such as agranulocytosis, have been reported with propranolol therapy. Non-thrombocytopenic purpura and thrombotic thrombocytopenic purpura (TTP) also have been reported.[28271]

Hypersensitivity reactions, including anaphylactic/anaphylactoid reactions, pharyngitis and agranulocytosis, erythematous rash, urticaria, fever combined with aching and sore throat, laryngospasm, and respiratory distress have been reported with propranolol use. Dermatologic reactions with beta-blockers are usually mild and transient. Some of these reactions include pruritus, reversible alopecia, xerosis, xerophthalmia, psoriaform rash, psoriasis, dermatitis psoriasiform, and exfoliative dermatitis. In addition, more serious dermatologic reactions have been reported including Stevens-Johnson Syndrome, toxic epidermal necrolysis, and erythema multiforme.[28271] [53642] [56853]

Lupus-like symptoms and systemic lupus erythematosus have been reported with the use of propranolol.[28271]

Withdrawal symptoms, including headache, diaphoresis, palpitations, sinus tachycardia, tremor, and hypertension, have been associated with abrupt discontinuation of beta-blockers in hypertensive patients. Gradual tapering and/or prolonged administration of small doses of propranolol prior to complete cessation may prevent these symptoms.[54110] [54113]

Revision Date: 12/18/2023, 12:53:34 PM

References

24483 - Bertram BL, Ma JZ, Kalil RSN, et al. Effects of antihypertensive therapy on serum lipids. Ann Intern Med 1995;122:133-41.26823 - Gress TW, Nieto FJ, Shahar E, et al. Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. N Engl J Med 2000;342:905-12.28271 - Propranolol tablet package insert. Parsippany, NJ: Actavis Pharma, Inc.; 2015 Aug.30575 - Luna B, Feinglos MN. Drug-induced hyperglycemia. JAMA 2001;286:1945-8.40143 - Innopran XL (propranolol hydrochloride) package insert. Baudette, MN: ANI Pharmaceuticals, Inc.; 2023 Dec.53617 - Inderal LA (propranolol sustained-release) capsules. Baudette, MN: ANI Pharmaceuticals, Inc. 2023 Nov.53642 - Kim GK, Del Rosso JQ. Drug-provoked psoriasis: is it drug induced or drug aggravated? Understanding pathophysiology and clinical relevance. J Clin Aesthet Dermatol 2010;3:32-38.53721 - Drolet BA, Frommelt PC, Chamlin SL. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics 2013;131:128-140.54110 - Rangno RE, Nattel S, Lutterodt A. prevention of propranolol withdrawal mechanism by prolonged small dose propranolol schedule. Am J Cardiol 1982;49:828-33.54113 - Prichard BN, Walden RJ. The syndrome associated with the withdrawal of beta-adrenergic receptor blocking drugs. Br J Clin Pharmacol 1982;13:337-43.56853 - Hemangeol (propranolol hydrochloride) oral solution package insert. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; 2021 Jun.67279 - Fathallah N, Slim R, Larif S, et al. Drug-induced hyperglycaemia and diabetes. Drug Saf 2015;38:1153-1168.67280 - Fonseca VA. Effects of beta-blockers on glucose and lipid metabolism. Curr Med Res Opin 2010;26:615-629.69076 - Aronson JK, ed. Beta-adrenoceptor antagonists. In: Meyler's Side Effects of Drugs. Elsevier 2016:897-927.

Contraindications/Precautions

Absolute contraindications are italicized.

  • acute heart failure
  • asthma
  • AV block
  • bradycardia
  • cardiogenic shock
  • neonates
  • pheochromocytoma
  • premature neonates
  • sick sinus syndrome
  • abrupt discontinuation
  • acute bronchospasm
  • beta-blocker hypersensitivity
  • breast-feeding
  • bronchitis
  • cerebrovascular disease
  • children
  • chronic obstructive pulmonary disease (COPD)
  • depression
  • diabetes mellitus
  • driving or operating machinery
  • emphysema
  • geriatric
  • hepatic disease
  • hyperthyroidism
  • hypoglycemia
  • hypotension
  • infants
  • myasthenia gravis
  • myopathy
  • obstetric delivery
  • PHACE syndrome
  • pregnancy
  • psoriasis
  • pulmonary disease
  • pulmonary edema
  • Raynaud's phenomenon
  • renal failure
  • renal impairment
  • stroke
  • surgery
  • thyroid disease
  • thyrotoxicosis
  • tobacco smoking
  • vasospastic angina
  • ventricular dysfunction
  • vomiting
  • Wolff-Parkinson-White syndrome

Abrupt discontinuation of any chronically administered beta-adrenergic blocking agent, such as propranolol, can result in the exacerbation of angina and, in some cases, myocardial ischemia or myocardial infarction, ventricular arrhythmias, or severe hypertension, especially in patients with preexisting cardiac disease. If chronic, oral propranolol therapy is to be discontinued, gradually decrease the dosage over a minimum of 2 weeks. Downward titration of parenteral therapy may be advisable if the patient will discontinue propranolol treatment. Advise patients and caregivers against interruption or cessation of therapy without the advice of a physician. If exacerbation of angina occurs during discontinuation of therapy, it is advised to reinstitute propranolol therapy and take other measures appropriate for the management of unstable angina.[28271] [45870] [53585] [53617]

Beta-blockers, like propranolol, should be used with caution in patients with hyperthyroidism or thyrotoxicosis because beta-blockade can mask tachycardia, which is a useful monitoring parameter in thyroid disease. Abrupt withdrawal of beta-blockers in a patient with hyperthyroidism can precipitate thyroid storm. Note that beta-blockers (particularly atenolol, propranolol and esmolol) are generally useful for the acute symptomatic treatment of the thyrotoxic patient. Beta-blockers can reduce tachycardia, tremor, and anxiety in the hyperthyroid patient.[28271]

Because beta-blockers, including propranolol, depress conduction through the AV node, they are contraindicated in patients with severe bradycardia or advanced AV block, unless a functioning pacemaker is present. Propranolol is also contraindicated in patients with sick sinus syndrome unless a functioning pacemaker is present. In addition, beta-blockers should be used with caution in combination with other drugs that depress conduction through the AV node. Reduction in heart rate and cardiac output may cause or worsen bradycardia and hypotension. Propranolol oral solution for infantile hemangioma (Hemangeol) is specifically contraindicated in babies with significant bradycardia (less than 80 beats per minute) or hypotension (blood pressure less than 50/30 mmHg).[56853] In general, beta-blockers should not be used in patients with acute pulmonary edema and are contraindicated in patients with cardiogenic shock or decompensated acute heart failure, particularly in those with severely compromised left ventricular dysfunction, because the negative inotropic effect of these drugs can further depress cardiac output. In stable patients with heart failure, however, beta-blockers (e.g., bisoprolol, carvedilol, metoprolol) given in low doses have been documented to be beneficial.[57101] Many beta-blockers are used in the treatment of hypertrophic cardiomyopathy. Propranolol oral solution for infantile hemangioma (Hemangeol) is strictly contraindicated in patients with pheochromocytoma.[56853] In general, beta-blocker monotherapy should be used with caution in patients with a pheochromocytoma or vasospastic angina (Prinzmetal's angina) because of the risk of hypertension secondary to unopposed alpha-receptor stimulation. In patients with pheochromocytoma, an alpha-blocking agent should be used prior to the initiation of any beta-blocker. In the treatment of myocardial infarction, beta-blockers are contraindicated in patients with hypotension (SBP less than 100 mmHg).[28271] [40143]

Beta-blockade in patients with Wolff-Parkinson-White syndrome and tachycardia can result in severe bradycardia requiring treatment with a pacemaker. In one case, this occurred after an initial propranolol dose of 5 mg.[28271]

Because of potential effects of beta-blockade on blood pressure and pulse, beta-blockers, like propranolol, should be used with caution in patients with cerebrovascular insufficiency (cerebrovascular disease) or stroke. If signs or symptoms suggesting reduced cerebral blood flow develop after initiation of beta-blocker, alternative therapy should be considered.[53631] In young patients being treated for an infantile hemangioma, propranolol therapy may increase the risk of stroke in PHACE syndrome (Posterior fossa anomalies, Hemangioma, Arterial lesions, Cardiac abnormalities/aortic coarctation, and abnormalities of the Eye) patients with severe cerebrovascular anomalies. Prior to initiation of propranolol therapy, investigate patients with large facial hemangiomas for potential arteriopathy associated with PHACE syndrome.[56853]

Beta-blockers may inhibit catecholamine-induced glycogenolysis, gluconeogenesis, and lipolysis, predisposing to hypoglycemia.[53721] [67279] Additionally, beta-blockers can also mask signs of hypoglycemia (e.g., tachycardia) and increase the risk for severe or prolonged hypoglycemia at any time during treatment, especially in persons with diabetes mellitus, children, and persons who are fasting (i.e., surgery, not eating regularly, or are vomiting)[53617] Hypoglycemia has been reported in patients taking propranolol after prolonged physical exertion. Persons with renal insufficiency may be more likely to have hypoglycemic reactions to propranolol.[28271] [53617] Pediatric patients receiving propranolol, particularly those younger than 3 months, are also at higher risk for drug-induced hypoglycemia.[53640] Persons should be instructed to seek emergency treatment if severe hypoglycemia occurs.[53617] Beta-blockers can also occasionally cause hyperglycemia. This is thought to be due to blockade of beta-2-receptors on pancreatic islet cells, which inhibit insulin secretion.[30575] [67279] In addition to acute blood glucose effects, beta-blockers have been shown to increase the risk of developing diabetes mellitus in adult hypertensive patients; evaluate this risk relative to the proven benefits of beta-blockers in reducing cardiovascular events.[26823] [67279] [67280]

Use propranolol with caution in patients with hepatic disease, because of possible decreased clearance of the drug; reduced doses may be indicated (see Dosage). Propranolol is extensively metabolized by the liver.[28271]

Propranolol is contraindicated in patients with bronchial asthma or a history of bronchospasm. Propranolol should generally not be used in patients with pulmonary disease (e.g., chronic obstructive pulmonary disease (COPD), emphysema, bronchitis), or during acute bronchospasm because bronchodilation can be inhibited.[28271] When used for the treatment of hemangioma, the FDA-approved product label recommends interrupting propranolol therapy in the event of a lower respiratory tract infection associated with dyspnea and wheezing.[56853]

Propranolol is contraindicated in patients exhibiting hypersensitivity to the drug or any of its excipients. Hypersensitivity reactions, including anaphylactic/anaphylactoid reactions, have been associated with the administration of propranolol.[28271] Do not use propranolol in patients with known beta-blocker hypersensitivity. Cross-sensitivity between beta-blockers may occur.[32916] [44577] [44579] [44580] In addition, patients receiving beta-blockers who have a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated allergen challenge and unresponsive to usual doses of epinephrine used to treat anaphylaxis.[28271] [56853]

Avoid propranolol in patients with Raynaud's phenomenon or peripheral vascular disease because reduced cardiac output and the relative increase in alpha stimulation can exacerbate symptoms.[53654]

Beta-blockers, like propranolol, may potentiate muscle weakness in patients with myasthenia gravis. Use propranolol with caution in patients with other underlying skeletal muscle disease. Isolated cases of exacerbation of myopathy and myotonia have been reported.[40143]

The use of propranolol has been associated with depression.[28271] Beta-blockers with high lipophilicity, such as propranolol, are more likely to cause CNS adverse effects, including depression. Propranolol should be avoided in patients with major depression; alternative hydrophilic beta-blocking agents (e.g., acebutolol, atenolol, nadolol) may be considered as alternative therapy.

Beta-blockers, like propranolol, may be associated with dizziness or drowsiness in some patients.[28271] Patients should be cautioned to avoid driving or operating machinery until the drug response is known.

Use propranolol with caution in patients with renal impairment because decreased plasma clearance may occur. In patients with renal failure, down-regulation of hepatic microsomal enzymes may result in decreased drug metabolism.[28271] [45870]

Beta-blockers, like propranolol, may exacerbate conditions such as psoriasis.[28271]

The necessity or desirability of withdrawing beta-blockers, such as propranolol, prior to major surgery is controversial; the risks versus benefits should be evaluated in individual patients. Patients receiving beta-blockers before or during surgery involving the use of general anesthetics with negative inotropic effects (e.g., ether, cyclopropane, or trichloroethylene) should be monitored closely for signs of heart failure. Severe, protracted hypotension and difficulty in restarting the heart have been reported after surgery in patients receiving beta-blockers. It should also be noted that because beta-blocker therapy reduces the ability of the heart to respond to beta-adrenergically mediated sympathetic reflex stimuli, the risks of general anesthesia and surgical procedures may be augmented. Although, gradual withdrawal of beta-blockers is sometimes recommended prior to general anesthesia to limit the potential for hypotension and heart failure, the manufacturer does not recommend withdrawal of chronically-administered propranolol prior to major surgery.[28271] The risk of precipitating adverse cardiac events (e.g., myocardial infarction, tachycardia) following preoperative withdrawal of beta-blockers may outweigh the risks of ongoing beta-blocker therapy, particularly in patients with co-existing cardiovascular disease. Consideration should be given to the type of surgery (e.g., cardiac vs. noncardiac), anesthetic strategy, and co-existing health conditions. The anesthetic technique may be modified to reduce the risk of concurrent beta-blocker therapy. If needed, the negative inotropic effects of beta-blockers may be cautiously reversed by sufficient doses of adrenergic agonists such as isoproterenol, dopamine, dobutamine, or norepinephrine. Vagal dominance, if it occurs, may be corrected with atropine (1—2 mg IV).

Propranolol oral solution for infantile hemangiomas (Hemangeol) is contraindicated in premature neonates, neonates, and infants with a corrected age younger than 5 weeks as well as any infant weighing less than 2 kg.[56853] Clinical guidelines recommend caution, but not exclusion, in infants younger than 5 weeks of age and/or postconceptual age younger than 48 weeks.[63864] Although other propranolol products are not FDA-approved for pediatric use, they are used clinically in patients as young as neonates. Bronchospasm and congestive heart failure have been reported coincident with propranolol use in children. Additionally, propranolol therapy can cause hypoglycemia, particularly in neonates, infants, and children.[28271] Propranolol-induced hypoglycemia may be more common during periods of fasting (e.g., irregular feeding schedules, preoperative intake abstinence, vomiting), after prolonged physical exertion, in patients with renal insufficiency, or when glucose demands are increased (e.g., cold, stress, infections).[28271] [53640] [56853] Neonates and infants younger than 3 months of age are at higher risk for drug-induced hypoglycemia; in patients receiving propranolol for hemangioma, doses should be held during periods of irregular feeding or vomiting.[53640] [56853] Hypoglycemic symptoms are often difficult to detect in infants and young children.[41518] Careful monitoring (vital signs, blood glucose concentrations) during initiation and slow dose escalation are recommended. Advise caregivers of appropriate measures to decrease the risk of hypoglycemia, focusing on the importance of frequent feedings (every 3 to 4 hours, with nutrition given shortly before or after administration). In addition, provide caregivers with special instructions for dosage adjustment or discontinuation during intercurrent illness (if clinical condition allows) and alternative dietary recommendations. Inform caregivers to discontinue propranolol and seek immediate medical attention if signs of hypoglycemia are present. Administration of dextrose-containing IV fluids may be necessary.[41518] [53640] [53721] [56853]

Prolonged experience with propranolol in pregnancy, based on published interventional and observational studies, has not identified a drug-associated risk of major birth defects, miscarriage, or other adverse maternal outcomes. Propranolol crosses the placenta. Bradycardia, hypoglycemia, and respiratory depression have been observed with exposure to beta-blockers in utero near the time of obstetric delivery. Monitor neonates with in utero exposure to propranolol closely at birth and manage accordingly. There are inconsistent reports of intrauterine growth restriction associated with propranolol; hypertension also increases fetal risk for intrauterine growth restriction.[40143]

Propranolol is present in human milk at low concentrations but the related risk to the breast-feeding infant is unknown.[40143] Propranolol has generally been considered compatible with breast-feeding in clinical use. Other beta-blockers that previous AAP recommendations regarded as usually compatible with breast-feeding include labetalol, metoprolol, nadolol, sotalol, and timolol; these agents may represent preferable alternatives for some patients.[27500] There is no data on the effects of propranolol on milk production. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.[40143]

Clinical studies of propranolol (various dosage forms) have generally not included sufficient numbers of geriatric subjects aged 65 and over to determine whether they respond differently from younger adults. Most clinical experience has not determined differences between geriatric and younger adult patients given propranolol. Geriatric subjects have decreased clearance and a longer mean elimination half-life of propranolol. These findings suggest that dose adjustment of propranolol may be required for older adult patients. In general, dose selection should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of the decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Adjust doses to tolerance and desired clinical response.[28271] [53617] [45870] [40143]

Tobacco smoking can increase the clearance rate of propranolol, due to induction of hepatic microsomal enzymes by the hydrocarbons in tobacco.[28271] At this time, no specific dosage recommendations are recommended for smokers. Because the effect on hepatic microsomal enzymes is not related to the nicotine component of tobacco, sudden smoking cessation may result in a reduced clearance of propranolol (and potentially other beta-blockers), despite the initiation of nicotine replacement. Monitor patients carefully when changes in smoking status occur.

Revision Date: 12/19/2023, 01:36:54 PM

References

26823 - Gress TW, Nieto FJ, Shahar E, et al. Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. N Engl J Med 2000;342:905-12.27500 - American Academy of Pediatrics (AAP) Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001;108(3):776-789.28271 - Propranolol tablet package insert. Parsippany, NJ: Actavis Pharma, Inc.; 2015 Aug.30575 - Luna B, Feinglos MN. Drug-induced hyperglycemia. JAMA 2001;286:1945-8.32916 - Lopressor (metoprolol tartrate) tablets and injection. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2012 Dec.40143 - Innopran XL (propranolol hydrochloride) package insert. Baudette, MN: ANI Pharmaceuticals, Inc.; 2023 Dec.41518 - Holland KE, Frieden IJ, Frommelt PC, et al. Hypoglycemia in children taking propranolol for the treatment of infantile hemangioma. Arch Dermatol. 2010;146(7):775-78.44577 - Aronson JK. Beta-adrenoceptor antagonists. In: Meyler's Side Effects of Drugs: The International Encyclopedia of Adverse Drug Reactions and Interactions. 15th ed. Elsevier; 2006:452-78.44579 - van Joost T, Smitt HS. Skin reactions to propranolol and cross-sensitivity to beta-adrenoreceptor blocking agents. Arch Dermatol 1981;117:600-1.44580 - van Joost TH, Middelkamp HJ, Ros FE. Dermatitis as a side-effect of long-term topical treatment with certain beta-blocking agents. Br J Dermatol 1978;101:171-6.45870 - Propranolol HCl injection package insert. Berkeley Heights, NJ: Hikma Pharmaceuticals USA Inc; 2022 May.53585 - propranolol oral solution package insert. Columbus, OH:Boehringer Ingelheim Roxane Laboratories; 2012 Jan.53617 - Inderal LA (propranolol sustained-release) capsules. Baudette, MN: ANI Pharmaceuticals, Inc. 2023 Nov.53631 - Webb AJ, Fischer U, Rothwell PM. Effects of beta-blocker selectivity on blood pressure variability and stroke. Neurology 2011;77:731-737.53640 - Lawley LP, Siegfried E, Todd JL. Propranolol treatment for hemangioma of infancy: risks and recommendations. Pediatr Derm 2009;26:610-614.53654 - Marshall AJ, Roberts CJ, Barritt DW. Raynaud's phenomenon as side effect of beta-blockers in hypertension. Br Med J 1976;1:1498-1499.53721 - Drolet BA, Frommelt PC, Chamlin SL. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics 2013;131:128-140.56853 - Hemangeol (propranolol hydrochloride) oral solution package insert. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; 2021 Jun.57101 - Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62:e147-239.63864 - Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics 2019;143:e20183475.67279 - Fathallah N, Slim R, Larif S, et al. Drug-induced hyperglycaemia and diabetes. Drug Saf 2015;38:1153-1168.67280 - Fonseca VA. Effects of beta-blockers on glucose and lipid metabolism. Curr Med Res Opin 2010;26:615-629.

Mechanism of Action

Mechanism of Action: Like other beta-adrenergic antagonists, propranolol competes with adrenergic neurotransmitters (e.g., catecholamines) for binding at sympathetic receptor sites. Similar to atenolol and metoprolol, propranolol blocks sympathetic stimulation mediated by beta1-adrenergic receptors in the heart and vascular smooth muscle. Pharmacodynamic consequences of beta1-receptor blockade include a decrease in both resting and exercise heart rate and cardiac output, and a decrease in both systolic and diastolic blood pressure. Propranolol may reduce reflex orthostatic hypotension. The fall in cardiac output induced by beta1 effects is often countered by a moderate reflex increase in peripheral vascular resistance that can be magnified by beta2 blockade (unmasked alpha stimulation). As a result, nonselective beta-blocking agents can produce a more modest decrease in (diastolic) blood pressure compared with selective beta1-antagonists. In addition, propranolol also can competitively block beta2-adrenergic responses in the bronchial muscles, potentially inducing bronchospasm.

Actions that make propranolol useful in treating hypertension include a negative chronotropic effect that decreases heart rate at rest and after exercise; a negative inotropic effect that decreases cardiac output; reduction of sympathetic outflow from the CNS; and suppression of renin release from the kidneys. Thus, propranolol, like other beta-blockers, affects blood pressure via multiple mechanisms. In general, beta-blockers without intrinsic sympathomimetic activity (ISA) exert detrimental effects on LVH and the lipid profile, and cause sexual dysfunction.

Actions that make propranolol useful in treating hypertension also apply to managing chronic stable angina. The reduction in myocardial oxygen demand induced by propranolol results in decreases in the frequency of anginal attacks and requirements of nitrate, and increases exercise tolerance. Other postulated anti-anginal actions include an increase in oxygen delivery to tissues, due to propranolol-induced lowering of hemoglobin's affinity for oxygen, and a reduction of platelet aggregation, postulated to be related to interference with calcium ion flux.

Propranolol has been used to treat portal hypertension and to prevent bleeding of esophageal varices. Nonselective beta-blockers decrease portal venous pressure, decrease blood flow in the superior portosystemic collateral circulation, and decrease blood flow in the splanchnic region.[24084] Beta-blockade decreases cardiac output reducing hepatic arterial and portal venous perfusion. Activation of unopposed alpha-receptors lead to splanchnic vasoconstriction, thus decreasing portal perfusion.[24085]

Propranolol is used to treat hypertension and the subsequent decline of renal function in patients with scleroderma renal crisis (SRC). SRC is associated with elevated peripheral renin concentrations. Propranolol blocks beta-receptors located on the surface of the juxtaglomerular cells which decreases the release of renin. In turn, this affects the renin-angiotensin-aldosterone system reducing blood pressure.

Numerous mechanisms may contribute to the efficacy of propranolol in preventing migraine headaches.[23792] Beta-blockade can prevent arterial dilation, inhibit renin secretion, and can interfere with catecholamine-induced lipolysis. A decrease in lipolysis decreases arachidonic acid synthesis and, subsequent, prostaglandin production. Inhibition of platelet aggregation is due to this decrease in prostaglandins and blockade of catecholamine-induced platelet adhesion. Other actions include increased oxygen delivery to tissues and prevention of coagulation during epinephrine release.

Propranolol has two roles in the treatment of thyrotoxicosis; these actions are determined by the different isomers of propranolol. L-propranolol causes beta-blockade and can ameliorate the symptoms associated with thytotoxicosis such as tremor, palpitations, anxiety, and heat intolerance. D-propranolol blocks the conversion of T4 to T3, but the therapeutic effect of this action is minimal.[24123]

Propranolol has been used in the management of hereditary or familial essential tremor. Beta-blockade controls the involuntary, rhythmic and oscillatory movements of essential tremor. Tremor amplitude is reduced, but not the frequency of tremor. The mechanism of action is unclear, but the antitremor effect may be mediated by blockade of peripheral beta2 receptor mechanisms.

Propranolol can dampen the peripheral physiologic symptoms of anxiety. Beta-blockade can attenuate somatic symptoms of anxiety such as palpitations and tremor, but it is less effective in controlling psychologic components, such as intense fear. These effects are thought to be due to improvement in somatic symptoms secondary to beta-blockade, although the mechanism of action is unclear.

Revision Date: 02/07/2009, 02:56:47 AM

References

23792 - Diamond S. Migraine headaches. Med Clin N Am 1991;75:545-66.24084 - Elder CA, Restino MSR. Beta-adrenergic antagonists for primary prevention of gastrointestinal hemorrhage in patients with cirrhosis and esophageal varices. Clin Pharm 1992;11:337-41.24085 - Reichen J. Liver function and pharmacological considerations in pathogenesis and treatment of portal hypertension. Hepatology 1990;6:1066-78.24123 - Eber O, Buchinger W, Lindner W, et al. The effect of D-versus L-propranolol in the treatment of hyperthyroidism. Clin Endocrinol 1990;32:363-72.

Pharmacokinetics

Propranolol is administered orally or intravenously. Propranolol is highly lipophilic and is widely distributed throughout the body. It readily crosses the blood-brain barrier and the placenta, and is distributed into breast milk. Propranolol is about 90% bound to plasma proteins, the R(+)-enantiomer primarily binds albumin while the S(-)-enantiomer is primarily bound to alpha-1 acid glycoprotein. The volume of distribution is about 4 L/kg. In normal subjects receiving oral doses of racemic propranolol, S(-)-enantiomer concentrations exceeded those of the R(+)-enantiomer by 40-90% as a result of stereoselective hepatic metabolism.[53617]

 

Propranolol is extensively metabolized upon first pass through the liver, and the extent of metabolism is dependent on liver blood flow. The drug also binds to and saturates nonspecific hepatic binding sites before the drug reaches the systemic circulation. An equipotent, pharmacologically active metabolite, 4-hydroxypropranolol, is produced with the initiation of oral therapy, but it is eliminated faster than the parent drug. With chronic or IV therapy, this metabolite is produced to a lesser degree. Overall, at least eight metabolites of propranolol have been identified. Important differences may exist among ethnic groups in the ability to metabolize propranolol, which can affect the overall efficacy of the drug in some instances. Excretion of propranolol occurs renally, primarily as metabolites, with only 1—4% of a dose excreted fecally as unchanged drug. Clearance of the pharmacologically active S(-)-propranolol is lower than R(+)-propranolol after intravenous and oral doses. The elimination half-life of propranolol ranges from 2—6 hours, with chronic administration yielding longer half-lives, possibly due to saturation of liver binding sites and/or systemic clearance.[53617]

 

Affected cytochrome P450 enzymes:

Cytochrome P450 enzymes involved in the metabolism of propranolol include 2D6, 1A2, and 2C19. Propranolol is also a substrate for the efflux transporter PGP.  The aromatic hydroxylation of propranolol to form the active metabolite, 4-hydroxypropranolol, is mediated by CYP2D6. 4-hydroxypropranolol is a substrate and weak inhibitor of CYP2D6. In healthy subjects, no difference in clearance or half-life of propranolol was observed between extensive and poor CYP2D6 metabolizers. In extensive metabolizers, a significant increase in 4-hydroxypropranolol clearance and a significant decrease in the clearance of naphthyloxyactic acid, an inactive metabolite, was noted.[53617]

Route-Specific Pharmacokinetics

Oral Route

After oral administration of immediate-release propranolol, the dose is almost completely absorbed, however, due to high first pass metabolism, bioavailability is only about 25%. Peak concentrations of immediate release tablets and long acting capsules are achieved in 1-4 hours and about 6 hours, respectively. Food can increase the bioavailability of the immediate release formulation by approximately 50% but does not affect the time to peak concentration. The effect of food on the bioavailability of the sustained-release formulation has not been investigated.[53617]

Intravenous Route

The distribution half-life of intervenously administered propranolol is 5 to 10 minutes. Pharmacodynamic effects are seen immediately and maintained for 2—4 hours.[45870]

Special Populations

Hepatic Impairment

Propranolol undergoes extensive hepatic metabolism and half-life appears to be prolonged in patients with hepatic impairment. In one study, 7 patients with cirrhosis were compared to 9 healthy subjects, each were given 7 doses of 80 mg propranolol every 8 hours. The half-life of propranolol was prolonged in patients with cirrhosis (11 hours) compared to healthy subjects (4 hours). On average, patients with cirrhosis had 3 times the concentration of unbound propranolol as the healthy subjects. A similar study, conducted with the long acting formulation, yielded a similar result with unbound propranolol concentrations increasing 2.5-fold in cirrhosis patients. After a single IV dose, the half-life of propranolol in cirrhosis patients and healthy subjects was 7.2 hours and 2.9 hours, respectively.[53617] Another study examined propranolol pharmacokinetics after a single 40 mg IV dose was given to 6 healthy subjects and 20 subjects with chronic liver disease, including hepatic cirrhosis. Patients with chronic liver disease had decreased clearance, increased volume of distribution, decreased protein binding, and increased variation in half-life compared to healthy subjects.[45870]

Renal Impairment

A reduced propranolol half-life has been reported in patients with renal impairment. This reduction in half-life is seen in conjunction with delayed absorption rate and peak propranolol plasma levels 3—4 fold higher than healthy subjects. In a single dose study comparing 5 chronic renal failure patients, 6 dialysis patients and 5 healthy subjects, peak propranolol concentrations in renal failure patients were 2—3 times higher than in dialysis patients or healthy subjects. The renal failure group also displayed reduced plasma propranolol clearance. However, propranolol is not appreciably removed by hemodialysis.[53617]

Pediatrics

Pharmacokinetics of propranolol oral solution were evaluated in a multiple dose 12 week study of infants with hemangioma (n = 23; age range: 35—150 days). Propranolol was initiated at 1.2 mg/kg/day PO and titrated at weekly intervals to a target dose of 3.4 mg/kg/day PO, divided into twice daily dosing. Plasma propranolol concentrations were dose-proportional in the range studied. At target dose steady state, peak plasma concentrations were observed within 2 hours. Clearance (2.7 L/kg/hour in infants < 90 days old and 3.3 L/kg/hour in infants > 90 days old) was similar to that in adults when adjusted for body weight. Median elimination half-life was 3.5 hours. The plasma concentration of 4-hydroxy propranolol was approximately 5% of total plasma exposure of propranolol.[56853]

Geriatric

Propranolol clearance appears to be reduced and half-life prolonged in the geriatric population. A single dose study of 32 patients of varying ages found an inverse correlation between age and clearance of propranolol metabolites (4 hydroxypropranolol and naphthoxylactic acid). A second study comparing 12 elderly (62—79 years old) and 12 young (25—33 years old) patients reported reduced clearance of the S(-) enantiomer in the elderly group. This study also reported prolonged half-life in the elderly (11 hours) compared to the young group (5 hours).[53617]

Gender Differences

Intravenous propranolol was evaluated in 5 women and 6 men. After adjusting for weight, no significant differences were found in half-life, volume of distribution, protein binding or clearance.[45870] In women, neither estradiol nor testosterone have demonstrated any change to propranolol plasma binding or clearance. Conflicting evidence exists in regard to the role of testosterone in propranolol metabolism and clearance in men.[53617]

Ethnic Differences

African-Americans appear to have increased propranolol clearance and Chinese may have increased unbound propranolol concentrations as compared to Caucasians. In a study of 12 Caucasian and 13 African-American men, clearance of both enantiomers was increased in the African-American group. Reported increase in clearance was 76% for the R(+) enantiomer and 53% for the S(-) enantiomer. In another study, unbound plasma propranolol was 18-45% higher in Chinese subjects than Caucasians.[53617]

Obesity

In one study, obese subjects had higher AUC and lower total clearance of IV propranolol than non-obese subjects. No significant difference between the groups was noted for plasma protein binding.[45870]

Other

Thyroid Dysfunction

No significant pharmacokinetic changes have been noted between hyperthyroid, hypothyroid and euthyroid subjects.[45870]

Revision Date: 04/01/2014, 10:24:12 AM

References

45870 - Propranolol HCl injection package insert. Berkeley Heights, NJ: Hikma Pharmaceuticals USA Inc; 2022 May.53617 - Inderal LA (propranolol sustained-release) capsules. Baudette, MN: ANI Pharmaceuticals, Inc. 2023 Nov.56853 - Hemangeol (propranolol hydrochloride) oral solution package insert. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; 2021 Jun.

Pregnancy/Breast-feeding

obstetric delivery, pregnancy

Prolonged experience with propranolol in pregnancy, based on published interventional and observational studies, has not identified a drug-associated risk of major birth defects, miscarriage, or other adverse maternal outcomes. Propranolol crosses the placenta. Bradycardia, hypoglycemia, and respiratory depression have been observed with exposure to beta-blockers in utero near the time of obstetric delivery. Monitor neonates with in utero exposure to propranolol closely at birth and manage accordingly. There are inconsistent reports of intrauterine growth restriction associated with propranolol; hypertension also increases fetal risk for intrauterine growth restriction.[40143]

breast-feeding

Propranolol is present in human milk at low concentrations but the related risk to the breast-feeding infant is unknown.[40143] Propranolol has generally been considered compatible with breast-feeding in clinical use. Other beta-blockers that previous AAP recommendations regarded as usually compatible with breast-feeding include labetalol, metoprolol, nadolol, sotalol, and timolol; these agents may represent preferable alternatives for some patients.[27500] There is no data on the effects of propranolol on milk production. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.[40143]

Revision Date: 08/24/2021, 08:52:32 AM

References

27500 - American Academy of Pediatrics (AAP) Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001;108(3):776-789.40143 - Innopran XL (propranolol hydrochloride) package insert. Baudette, MN: ANI Pharmaceuticals, Inc.; 2023 Dec.

Interactions

Level 1 (Severe)

  • Thioridazine

Level 2 (Major)

  • Amifostine
  • Aspirin, ASA; Citric Acid; Sodium Bicarbonate
  • Aspirin, ASA; Dipyridamole
  • Bupivacaine
  • Bupivacaine Liposomal
  • Bupivacaine; Epinephrine
  • Bupivacaine; Lidocaine
  • Bupivacaine; Meloxicam
  • Ceritinib
  • Cevimeline
  • Cocaine
  • Crizotinib
  • Desvenlafaxine
  • Dextromethorphan; Quinidine
  • Diltiazem
  • Dipyridamole
  • Disopyramide
  • Dronedarone
  • Etomidate
  • Fenoldopam
  • Fexinidazole
  • Fingolimod
  • food
  • General anesthetics
  • Iobenguane I 131
  • Isoflurane
  • Ketamine
  • Lidocaine
  • Lidocaine; Epinephrine
  • Lidocaine; Prilocaine
  • Lofexidine
  • Mefloquine
  • Mepivacaine
  • Methohexital
  • Nesiritide, BNP
  • Omeprazole; Sodium Bicarbonate
  • Oxymetazoline
  • Pasireotide
  • Procainamide
  • Propafenone
  • Propofol
  • Quinidine
  • Rizatriptan
  • Rolapitant
  • Sevoflurane
  • Sodium Bicarbonate
  • Theophylline, Aminophylline
  • tobacco
  • Trandolapril; Verapamil
  • Tranylcypromine
  • Verapamil

Level 3 (Moderate)

  • Abiraterone
  • Acarbose
  • Acetaminophen; Aspirin
  • Acetaminophen; Aspirin, ASA; Caffeine
  • Acetaminophen; Aspirin; Diphenhydramine
  • Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine
  • Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine
  • Acetaminophen; Chlorpheniramine; Phenylephrine
  • Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine
  • Acetaminophen; Dextromethorphan; Guaifenesin; Pseudoephedrine
  • Acetaminophen; Dextromethorphan; Phenylephrine
  • Acetaminophen; Dextromethorphan; Pseudoephedrine
  • Acetaminophen; Dichloralphenazone; Isometheptene
  • Acetaminophen; Guaifenesin; Phenylephrine
  • Acetaminophen; Ibuprofen
  • Acetaminophen; Phenylephrine
  • Acetaminophen; Pseudoephedrine
  • Aclidinium; Formoterol
  • Acrivastine; Pseudoephedrine
  • Adagrasib
  • Adenosine
  • Albuterol
  • Albuterol; Budesonide
  • Aldesleukin, IL-2
  • Alemtuzumab
  • Alfentanil
  • Alfuzosin
  • Alogliptin
  • Alogliptin; Metformin
  • Alogliptin; Pioglitazone
  • Alpha-blockers
  • Alpha-glucosidase Inhibitors
  • Aluminum Hydroxide
  • Aluminum Hydroxide; Magnesium Carbonate
  • Aluminum Hydroxide; Magnesium Hydroxide
  • Aluminum Hydroxide; Magnesium Hydroxide; Simethicone
  • Aluminum Hydroxide; Magnesium Trisilicate
  • Amiodarone
  • Amlodipine
  • Amlodipine; Atorvastatin
  • Amlodipine; Benazepril
  • Amlodipine; Celecoxib
  • Amlodipine; Olmesartan
  • Amlodipine; Valsartan
  • Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ
  • Amobarbital
  • Amphetamine
  • Amphetamine; Dextroamphetamine
  • Antacids
  • Apalutamide
  • Apomorphine
  • Arformoterol
  • Armodafinil
  • Artemether; Lumefantrine
  • Articaine; Epinephrine
  • Asenapine
  • Aspirin, ASA
  • Aspirin, ASA; Butalbital; Caffeine
  • Aspirin, ASA; Caffeine
  • Aspirin, ASA; Caffeine; Orphenadrine
  • Aspirin, ASA; Carisoprodol; Codeine
  • Aspirin, ASA; Omeprazole
  • Aspirin, ASA; Oxycodone
  • Atazanavir
  • Atazanavir; Cobicistat
  • Atracurium
  • Azelastine; Fluticasone
  • Baclofen
  • Beclomethasone
  • Benzphetamine
  • Berotralstat
  • Beta-agonists
  • Betamethasone
  • Bexagliflozin
  • Bismuth Subsalicylate
  • Bismuth Subsalicylate; Metronidazole; Tetracycline
  • Bretylium
  • Brexpiprazole
  • Brompheniramine; Dextromethorphan; Phenylephrine
  • Brompheniramine; Phenylephrine
  • Brompheniramine; Pseudoephedrine
  • Brompheniramine; Pseudoephedrine; Dextromethorphan
  • Budesonide
  • Budesonide; Formoterol
  • Budesonide; Glycopyrrolate; Formoterol
  • Butalbital; Aspirin; Caffeine; Codeine
  • Cabergoline
  • Calcium Carbonate
  • Calcium Carbonate; Famotidine; Magnesium Hydroxide
  • Calcium Carbonate; Magnesium Hydroxide
  • Calcium Carbonate; Magnesium Hydroxide; Simethicone
  • Calcium Carbonate; Simethicone
  • Calcium; Vitamin D
  • Canagliflozin
  • Canagliflozin; Metformin
  • Cannabidiol
  • Capivasertib
  • Capmatinib
  • Carbidopa; Levodopa
  • Carbidopa; Levodopa; Entacapone
  • Cariprazine
  • Celecoxib
  • Celecoxib; Tramadol
  • Cenobamate
  • Cetirizine; Pseudoephedrine
  • Chlophedianol; Dexchlorpheniramine; Pseudoephedrine
  • Chloroprocaine
  • Chlorpheniramine; Dextromethorphan; Phenylephrine
  • Chlorpheniramine; Dextromethorphan; Pseudoephedrine
  • Chlorpheniramine; Ibuprofen; Pseudoephedrine
  • Chlorpheniramine; Phenylephrine
  • Chlorpheniramine; Pseudoephedrine
  • Chlorpromazine
  • Chlorpropamide
  • Cholestyramine
  • Choline Salicylate; Magnesium Salicylate
  • Ciclesonide
  • Cimetidine
  • Cinacalcet
  • Cisatracurium
  • Clevidipine
  • Clobazam
  • Clonidine
  • Clozapine
  • Co-Enzyme Q10, Ubiquinone
  • Cobicistat
  • Codeine; Guaifenesin; Pseudoephedrine
  • Codeine; Phenylephrine; Promethazine
  • Colestipol
  • Corticosteroids
  • Cortisone
  • Dacomitinib
  • Dapagliflozin
  • Dapagliflozin; Metformin
  • Dapagliflozin; Saxagliptin
  • Darifenacin
  • Darunavir; Cobicistat
  • Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide
  • Deflazacort
  • Delavirdine
  • Desflurane
  • Desloratadine; Pseudoephedrine
  • Dexamethasone
  • Dexbrompheniramine; Pseudoephedrine
  • Dexchlorpheniramine; Dextromethorphan; Pseudoephedrine
  • Dexmedetomidine
  • Dexmethylphenidate
  • Dextroamphetamine
  • Dextromethorphan; Diphenhydramine; Phenylephrine
  • Dextromethorphan; Guaifenesin; Phenylephrine
  • Dextromethorphan; Guaifenesin; Pseudoephedrine
  • Diazoxide
  • Diclofenac
  • Diclofenac; Misoprostol
  • Diethylpropion
  • Diflunisal
  • Digoxin
  • Dihydroergotamine
  • Dipeptidyl Peptidase-4 Inhibitors
  • Diphenhydramine; Ibuprofen
  • Diphenhydramine; Naproxen
  • Diphenhydramine; Phenylephrine
  • Dobutamine
  • Donepezil
  • Donepezil; Memantine
  • Dopamine
  • Doxapram
  • Doxazosin
  • Dulaglutide
  • Duloxetine
  • Eliglustat
  • Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide
  • Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate
  • Empagliflozin
  • Empagliflozin; Linagliptin
  • Empagliflozin; Linagliptin; Metformin
  • Empagliflozin; Metformin
  • Enasidenib
  • Ephedrine
  • Ephedrine; Guaifenesin
  • Epinephrine
  • Epoprostenol
  • Ergotamine
  • Ergotamine; Caffeine
  • Ertugliflozin
  • Ertugliflozin; Metformin
  • Ertugliflozin; Sitagliptin
  • Ethiodized Oil
  • Etodolac
  • Etrasimod
  • Everolimus
  • Exenatide
  • Fedratinib
  • Fenoprofen
  • Fexofenadine; Pseudoephedrine
  • Fish Oil, Omega-3 Fatty Acids (Dietary Supplements)
  • Flecainide
  • Fludrocortisone
  • Flunisolide
  • Fluorescein
  • Fluoxetine
  • Flurbiprofen
  • Fluticasone
  • Fluticasone; Salmeterol
  • Fluticasone; Umeclidinium; Vilanterol
  • Fluticasone; Vilanterol
  • Fluvoxamine
  • Formoterol
  • Formoterol; Mometasone
  • Galantamine
  • Glimepiride
  • Glipizide
  • Glipizide; Metformin
  • Glyburide
  • Glyburide; Metformin
  • Glycopyrrolate; Formoterol
  • Guaifenesin; Phenylephrine
  • Guaifenesin; Pseudoephedrine
  • Guanfacine
  • Haloperidol
  • Hydralazine; Isosorbide Dinitrate, ISDN
  • Hydrocodone; Ibuprofen
  • Hydrocodone; Pseudoephedrine
  • Hydrocortisone
  • Ibuprofen
  • Ibuprofen; Famotidine
  • Ibuprofen; Oxycodone
  • Ibuprofen; Pseudoephedrine
  • Icosapent ethyl
  • Iloperidone
  • Iloprost
  • Imatinib
  • Incretin Mimetics
  • Indacaterol; Glycopyrrolate
  • Indomethacin
  • Insulin Aspart
  • Insulin Aspart; Insulin Aspart Protamine
  • Insulin Degludec
  • Insulin Degludec; Liraglutide
  • Insulin Detemir
  • Insulin Glargine
  • Insulin Glargine; Lixisenatide
  • Insulin Glulisine
  • Insulin Lispro
  • Insulin Lispro; Insulin Lispro Protamine
  • Insulin, Inhaled
  • Insulins
  • Intravenous Lipid Emulsions
  • Iodixanol
  • Iohexol
  • Iomeprol
  • Iopamidol
  • Iopromide
  • Ioversol
  • Ipratropium; Albuterol
  • Isocarboxazid
  • Isoniazid, INH; Pyrazinamide, PZA; Rifampin
  • Isoniazid, INH; Rifampin
  • Isophane Insulin (NPH)
  • Isoproterenol
  • Isosorbide Dinitrate, ISDN
  • Isosorbide Mononitrate
  • Isosulfan Blue
  • Isradipine
  • Ivabradine
  • Ketoprofen
  • Ketorolac
  • Lacosamide
  • Lanreotide
  • Lasmiditan
  • Levalbuterol
  • Levamlodipine
  • Levodopa
  • Linagliptin
  • Linagliptin; Metformin
  • Linezolid
  • Liraglutide
  • Lisdexamfetamine
  • Lixisenatide
  • Lonafarnib
  • Lopinavir; Ritonavir
  • Loratadine; Pseudoephedrine
  • Lurasidone
  • Magnesium Hydroxide
  • Magnesium Salicylate
  • Mavacamten
  • Meclofenamate Sodium
  • Mefenamic Acid
  • Meglitinides
  • Meloxicam
  • Metaproterenol
  • Metformin
  • Metformin; Repaglinide
  • Metformin; Saxagliptin
  • Metformin; Sitagliptin
  • Methacholine
  • Methamphetamine
  • Methylergonovine
  • Methylphenidate
  • Methylprednisolone
  • Mexiletine
  • Midodrine
  • Miglitol
  • Milrinone
  • Mirabegron
  • Modafinil
  • Mometasone
  • Nabumetone
  • Naproxen
  • Naproxen; Esomeprazole
  • Naproxen; Pseudoephedrine
  • Nateglinide
  • Neuromuscular blockers
  • Niacin, Niacinamide
  • Nicardipine
  • Nifedipine
  • Nimodipine
  • Niraparib; Abiraterone
  • Nirmatrelvir; Ritonavir
  • Nisoldipine
  • Nitrates
  • Nitroglycerin
  • Nitroprusside
  • Non-Ionic Contrast Media
  • Nonsteroidal antiinflammatory drugs
  • Norepinephrine
  • Octreotide
  • Olanzapine
  • Olanzapine; Fluoxetine
  • Olanzapine; Samidorphan
  • Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ
  • Olodaterol
  • Olopatadine; Mometasone
  • Omeprazole; Amoxicillin; Rifabutin
  • Oritavancin
  • Osilodrostat
  • Oxaprozin
  • Ozanimod
  • Paliperidone
  • Pancuronium
  • Peginterferon Alfa-2b
  • Pentoxifylline
  • Perindopril; Amlodipine
  • Perphenazine
  • Perphenazine; Amitriptyline
  • Phendimetrazine
  • Phenelzine
  • Phenoxybenzamine
  • Phentermine
  • Phentermine; Topiramate
  • Phentolamine
  • Phenylephrine
  • Pilocarpine
  • Pioglitazone
  • Pioglitazone; Glimepiride
  • Pioglitazone; Metformin
  • Piroxicam
  • Ponesimod
  • Pramlintide
  • Prazosin
  • Prednisolone
  • Prednisone
  • Prilocaine
  • Prilocaine; Epinephrine
  • Primidone
  • Promethazine; Phenylephrine
  • Pseudoephedrine
  • Pseudoephedrine; Triprolidine
  • Racepinephrine
  • Ranolazine
  • Rasagiline
  • Regular Insulin
  • Regular Insulin; Isophane Insulin (NPH)
  • Remifentanil
  • Repaglinide
  • Rifabutin
  • Rifampin
  • Rifamycins
  • Rifapentine
  • Risperidone
  • Ritlecitinib
  • Ritonavir
  • Rivastigmine
  • Rocuronium
  • Ropivacaine
  • Rosiglitazone
  • Rucaparib
  • Salmeterol
  • Salsalate
  • Saxagliptin
  • Semaglutide
  • Serdexmethylphenidate; Dexmethylphenidate
  • SGLT2 Inhibitors
  • Silodosin
  • Siponimod
  • Sitagliptin
  • Sotagliflozin
  • Succinylcholine
  • Sufentanil
  • Sulfonylureas
  • Sulindac
  • Sumatriptan; Naproxen
  • Sympathomimetics
  • Tasimelteon
  • Telmisartan; Amlodipine
  • Terazosin
  • Terbutaline
  • Tetrabenazine
  • Tetracaine
  • Thalidomide
  • Thiazolidinediones
  • Thiothixene
  • Tiotropium; Olodaterol
  • Tirzepatide
  • Tizanidine
  • Tolmetin
  • Triamcinolone
  • Trifluoperazine
  • Umeclidinium; Vilanterol
  • Vecuronium
  • Vemurafenib
  • Viloxazine
  • Voriconazole
  • Warfarin
  • Zileuton

Level 4 (Minor)

  • Alprostadil
  • Antithyroid agents
  • Apraclonidine
  • Aripiprazole
  • Ascorbic Acid, Vitamin C
  • Bupropion
  • Bupropion; Naltrexone
  • Citalopram
  • Dasiglucagon
  • Dextromethorphan; Bupropion
  • Dutasteride; Tamsulosin
  • Eletriptan
  • Escitalopram
  • Estradiol
  • Ezetimibe; Simvastatin
  • Fenofibric Acid
  • Fosphenytoin
  • Gabapentin
  • Ginger, Zingiber officinale
  • Glucagon
  • Indocyanine Green
  • Levothyroxine
  • Levothyroxine; Liothyronine (Porcine)
  • Levothyroxine; Liothyronine (Synthetic)
  • Liothyronine
  • Lumacaftor; Ivacaftor
  • Lumacaftor; Ivacaftor
  • Methimazole
  • Nefazodone
  • Paroxetine
  • Phenytoin
  • Propylthiouracil, PTU
  • Quinine
  • Simvastatin
  • Tamsulosin
  • Terbinafine
  • Thyroid hormones
  • Trazodone
  • Ziprasidone
  • Zolmitriptan
Abiraterone: (Moderate) Monitor blood pressure and heart rate if coadministration of propranolol with abiraterone is necessary. Propranolol is a CYP2D6 substrate and abiraterone is a CYP2D6 inhibitor. Concomitant use may result in hypotension and bradycardia. [44156] [45870] [56853] Acarbose: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Acetaminophen; Aspirin, ASA; Caffeine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Acetaminophen; Aspirin: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Acetaminophen; Aspirin; Diphenhydramine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Chlorpheniramine; Phenylephrine : (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Dextromethorphan; Guaifenesin; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Dextromethorphan; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Dextromethorphan; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Dichloralphenazone; Isometheptene: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Guaifenesin; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Ibuprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Acetaminophen; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Acetaminophen; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Aclidinium; Formoterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Acrivastine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Adagrasib: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of adagrasib as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and adagrasib is moderate CYP2D6 inhibitor. [45870] [56853] [68325] Adenosine: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes. [43606] Albuterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Albuterol; Budesonide: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Aldesleukin, IL-2: (Moderate) Beta blockers may potentiate the hypotension seen with aldesleukin, IL 2. [41853] Alemtuzumab: (Moderate) Alemtuzumab may cause hypotension. Careful monitoring of blood pressure and hypotensive symptoms is recommended especially in patients with ischemic heart disease and in patients on antihypertensive agents. [27942] Alfentanil: (Moderate) Alfentanil may cause bradycardia. The risk of significant hypotension and/or bradycardia during therapy with alfentanil is increased in patients receiving beta-blockers. [7463] Alfuzosin: (Moderate) The manufacturer warns that the combination of alfuzosin with antihypertensive agents has the potential to cause hypotension in some patients. Alfuzosin (2.5 mg, immediate-release) potentiated the hypotensive effects of atenolol (100 mg) in eight healthy young male volunteers. The Cmax and AUC of alfuzosin was increased by 28% and 21%, respectively. Alfuzosin increased the Cmax and AUC of atenolol by 26% and 14%, respectively. Significant reductions in mean blood pressure and in mean heart rate were reported with the combination. [28261] Alogliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Alogliptin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Alogliptin; Pioglitazone: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Alpha-blockers: (Moderate) Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. [30211] Alpha-glucosidase Inhibitors: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Alprostadil: (Minor) The concomitant use of systemic alprostadil injection and antihypertensive agents, such as beta-clockers, may cause additive hypotension. Caution is advised with this combination. Systemic drug interactions with the urethral suppository (MUSE) or alprostadil intracavernous injection are unlikely in most patients because low or undetectable amounts of the drug are found in the peripheral venous circulation following administration. In those men with significant corpora cavernosa venous leakage, hypotension might be more likely. Use caution with in-clinic dosing for erectile dysfunction (ED) and monitor for the effects on blood pressure. In addition, the presence of medications in the circulation that attenuate erectile function may influence the response to alprostadil. However, in clinical trials with alprostadil intracavernous injection, anti-hypertensive agents had no apparent effect on the safety and efficacy of alprostadil. [30847] [30849] [55990] Aluminum Hydroxide: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Aluminum Hydroxide; Magnesium Carbonate: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Aluminum Hydroxide; Magnesium Hydroxide: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Aluminum Hydroxide; Magnesium Hydroxide; Simethicone: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Aluminum Hydroxide; Magnesium Trisilicate: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Amifostine: (Major) Patients receiving beta-blockers should be closely monitored during amifostine infusions due to additive effects. Patients receiving amifostine at doses recommended for chemotherapy should have antihypertensive therapy interrupted 24 hours preceding administration of amifostine. If the antihypertensive cannot be stopped, patients should not receive amifostine. [49124] Amiodarone: (Moderate) Concomitant administration of propranolol with amiodarone may cause additive electrophysiologic effects (slow sinus rate or worsen AV block), resulting in symptomatic bradycardia, sinus arrest, and atrioventricular block. This is particularly likely in patients with preexisting partial AV block or sinus node dysfunction. Because amiodarone is an inhibitor of CYP2D6, decreased clearance of propranolol, which is a CYP2D6 substrate, is also possible. Caution and close monitoring are recommended during coadministration; a dose reduction of one or both drugs may be needed based on response. It should be noted that post-hoc analysis of amiodarone therapy in patients after acute myocardial infarction in two clinical trials revealed that amiodarone in addition to a beta-blocker significantly lowered the incidence of cardiac and arrhythmic death or resuscitated cardiac arrest when compared with amiodarone or beta-blocker therapy alone. [28224] [28271] [28295] [28296] [28896] [49632] [53671] Amlodipine: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Amlodipine; Atorvastatin: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Amlodipine; Benazepril: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Amlodipine; Celecoxib: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Amlodipine; Olmesartan: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Amlodipine; Valsartan: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Amobarbital: (Moderate) Although concurrent use of amobarbital with antihypertensive agents may lead to hypotension, barbiturates, as a class, can enhance the hepatic metabolism of beta-blockers that are significantly metabolized by the liver. Beta-blockers that may be affected include betaxolol, labetalol, metoprolol, pindolol, propranolol, and timolol. Clinicians should closely monitor patients blood pressure during times of coadministration. [4718] [5269] [6532] Amphetamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Amphetamine; Dextroamphetamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Antacids: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Antithyroid agents: (Minor) Hyperthyroidism may cause increased clearance of beta blockers that possess a high extraction ratio. A dose reduction of some beta-blockers may be needed when a hyperthyroid patient treated with methimazole becomes euthyroid. [5176] Apalutamide: (Moderate) Monitor for decreased efficacy of propranolol if coadministration with apalutamide is necessary. Propranolol is a CYP2C19 substrate and apalutamide is a strong CYP2C19 inducer. [45870] [56853] [62874] Apomorphine: (Moderate) Use of beta blockers and apomorphine together can increase the hypotensive effects of apomorphine. Monitor blood pressure regularly during use of this combination. [28661] Apraclonidine: (Minor) Theoretically, additive blood pressure reductions could occur when apraclonidine is combined with antihypertensive agents. [29484] Arformoterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Aripiprazole: (Minor) Aripiprazole may enhance the hypotensive effects of antihypertensive agents. It may be advisable to monitor blood pressure when these medications are coadministered. [42845] Armodafinil: (Moderate) In vitro data indicate that armodafinil is an inhibitor of CYP2C19. In theory, dosage reductions may be required for drugs that are largely eliminated via CYP2C19 metabolism such as propranolol during coadministration with armodafinil. [33467] Artemether; Lumefantrine: (Moderate) Lumefantrine is an inhibitor and propranolol is a substrate of the CYP2D6 isoenzyme; therefore, coadministration may lead to increased propranolol concentrations. Concomitant use warrants caution due to the potential for increased side effects. [35401] [4998] Articaine; Epinephrine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Thus, patients receiving antihypertensive agents may experience additive hypotensive effects. [5731] [5815] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Ascorbic Acid, Vitamin C: (Minor) Ascorbic acid may reduce the oral bioavailability of propranolol. Advise patients against taking large doses of ascorbic acid with doses of propranolol. [5942] Asenapine: (Moderate) Secondary to alpha-blockade, asenapine can produce vasodilation that may result in additive effects during concurrent use of propranolol. The potential reduction in blood pressure can precipitate orthostatic hypotension and associated dizziness, tachycardia, and syncope. If concurrent use is necessary, patients should be counseled on measures to prevent orthostatic hypotension, such as sitting on the edge of the bed for several minutes prior to standing in the morning and rising slowly from a seated position. Close monitoring of blood pressure is recommended until the full effects of the combination therapy are known; the propranolol dosage may need to be adjusted. [36343] Aspirin, ASA: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Butalbital; Caffeine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Caffeine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Caffeine; Orphenadrine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Carisoprodol; Codeine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Citric Acid; Sodium Bicarbonate: (Major) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [4498] (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Dipyridamole: (Major) Beta-blockers should generally be withheld before dipyridamole-stress testing. Monitor the heart rate carefully following the dipyridamole injection. [32916] (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Omeprazole: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Aspirin, ASA; Oxycodone: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Atazanavir: (Moderate) Atazanavir can prolong the PR interval. Coadministration with other agents that prolong the PR interval, like beta blockers, may result in elevated risk of conduction disturbances and atrioventricular block. [28142] Atazanavir; Cobicistat: (Moderate) Atazanavir can prolong the PR interval. Coadministration with other agents that prolong the PR interval, like beta blockers, may result in elevated risk of conduction disturbances and atrioventricular block. [28142] (Moderate) Coadministration of cobicistat (a CYP2D6 inhibitor) with beta-blockers metabolized by CYP2D6, such as propranolol, may result in elevated beta-blocker serum concentrations. If used concurrently, close clinical monitoring with appropriate beta-blocker dose reductions are advised. [53617] [58000] Atracurium: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Azelastine; Fluticasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Baclofen: (Moderate) Baclofen has been associated with hypotension. Concurrent use with baclofen and antihypertensive agents may result in additive hypotension. Dosage adjustments of the antihypertensive medication may be required. [30582] [57272] Beclomethasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Benzphetamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Berotralstat: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of berotralstat as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and berotralstat is moderate CYP2D6 inhibitor. [45870] [56853] [66159] Beta-agonists: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Betamethasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Bexagliflozin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Bismuth Subsalicylate: (Moderate) Concurrent use of beta-blockers with bismuth subsalicylate and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concurrent use of beta-blockers with bismuth subsalicylate and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Bretylium: (Moderate) Bretylium and beta-blockers may have an additive effect when used concomitantly; monitor for hypotension or marked bradycardia, which may produce vertigo, syncope, or postural hypotension. [28539] [64910] Brexpiprazole: (Moderate) Due to brexpiprazole's antagonism at alpha 1-adrenergic receptors, the drug may enhance the hypotensive effects of alpha-blockers and other antihypertensive agents. [59949] Brompheniramine; Dextromethorphan; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Brompheniramine; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Brompheniramine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Brompheniramine; Pseudoephedrine; Dextromethorphan: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Budesonide: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Budesonide; Formoterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Budesonide; Glycopyrrolate; Formoterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Bupivacaine Liposomal: (Major) Propranolol has been shown to significantly decrease the clearance of the amide local anesthetics (e.g., lidocaine, bupivacaine, and mepivacaine). Lidocaine and bupivacaine toxicity have been reported after coadministration with propranolol. The mechanism of the interaction between propranolol and lidocaine is thought to be due to propranolol-induced decreased hepatic blood flow causing decreased elimination of lidocaine. Local anesthetics may also cause additive hypotension in combination with antihypertensive agents. Use extreme caution with the concomitant use of bupivacaine and antihypertensive agents or rapid-onset vasodilators, such as nitrates. Peripheral vasodilation may occur after use of bupivacaine. Thus, patients receiving antihypertensive agents may experience additive hypotensive effects. Blood concentrations of local anesthetics achieved after therapeutic doses are associated with minimal change in peripheral vascular resistance. Higher blood concentrations of local anesthetics may occur due to inadvertent intravascular administration or repeated doses. [40143] Bupivacaine: (Major) Propranolol has been shown to significantly decrease the clearance of the amide local anesthetics (e.g., lidocaine, bupivacaine, and mepivacaine). Lidocaine and bupivacaine toxicity have been reported after coadministration with propranolol. The mechanism of the interaction between propranolol and lidocaine is thought to be due to propranolol-induced decreased hepatic blood flow causing decreased elimination of lidocaine. Local anesthetics may also cause additive hypotension in combination with antihypertensive agents. Use extreme caution with the concomitant use of bupivacaine and antihypertensive agents or rapid-onset vasodilators, such as nitrates. Peripheral vasodilation may occur after use of bupivacaine. Thus, patients receiving antihypertensive agents may experience additive hypotensive effects. Blood concentrations of local anesthetics achieved after therapeutic doses are associated with minimal change in peripheral vascular resistance. Higher blood concentrations of local anesthetics may occur due to inadvertent intravascular administration or repeated doses. [40143] Bupivacaine; Epinephrine: (Major) Propranolol has been shown to significantly decrease the clearance of the amide local anesthetics (e.g., lidocaine, bupivacaine, and mepivacaine). Lidocaine and bupivacaine toxicity have been reported after coadministration with propranolol. The mechanism of the interaction between propranolol and lidocaine is thought to be due to propranolol-induced decreased hepatic blood flow causing decreased elimination of lidocaine. Local anesthetics may also cause additive hypotension in combination with antihypertensive agents. Use extreme caution with the concomitant use of bupivacaine and antihypertensive agents or rapid-onset vasodilators, such as nitrates. Peripheral vasodilation may occur after use of bupivacaine. Thus, patients receiving antihypertensive agents may experience additive hypotensive effects. Blood concentrations of local anesthetics achieved after therapeutic doses are associated with minimal change in peripheral vascular resistance. Higher blood concentrations of local anesthetics may occur due to inadvertent intravascular administration or repeated doses. [40143] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Bupivacaine; Lidocaine: (Major) Drugs such as beta-blockers that decrease cardiac output reduce hepatic blood flow and thereby decrease lidocaine hepatic clearance. Also, opposing effects on conduction exist between lidocaine and beta-blockers while their effects to decrease automaticity may be additive. Propranolol has been shown to decrease lidocaine clearance and symptoms of lidocaine toxicity have been seen as a result of this interaction. This interaction is possible with other beta-blocking agents since most decrease hepatic blood flow. Monitoring of lidocaine concentrations is recommended during concomitant therapy with beta-blockers. [40143] [5001] (Major) Propranolol has been shown to significantly decrease the clearance of the amide local anesthetics (e.g., lidocaine, bupivacaine, and mepivacaine). Lidocaine and bupivacaine toxicity have been reported after coadministration with propranolol. The mechanism of the interaction between propranolol and lidocaine is thought to be due to propranolol-induced decreased hepatic blood flow causing decreased elimination of lidocaine. Local anesthetics may also cause additive hypotension in combination with antihypertensive agents. Use extreme caution with the concomitant use of bupivacaine and antihypertensive agents or rapid-onset vasodilators, such as nitrates. Peripheral vasodilation may occur after use of bupivacaine. Thus, patients receiving antihypertensive agents may experience additive hypotensive effects. Blood concentrations of local anesthetics achieved after therapeutic doses are associated with minimal change in peripheral vascular resistance. Higher blood concentrations of local anesthetics may occur due to inadvertent intravascular administration or repeated doses. [40143] Bupivacaine; Meloxicam: (Major) Propranolol has been shown to significantly decrease the clearance of the amide local anesthetics (e.g., lidocaine, bupivacaine, and mepivacaine). Lidocaine and bupivacaine toxicity have been reported after coadministration with propranolol. The mechanism of the interaction between propranolol and lidocaine is thought to be due to propranolol-induced decreased hepatic blood flow causing decreased elimination of lidocaine. Local anesthetics may also cause additive hypotension in combination with antihypertensive agents. Use extreme caution with the concomitant use of bupivacaine and antihypertensive agents or rapid-onset vasodilators, such as nitrates. Peripheral vasodilation may occur after use of bupivacaine. Thus, patients receiving antihypertensive agents may experience additive hypotensive effects. Blood concentrations of local anesthetics achieved after therapeutic doses are associated with minimal change in peripheral vascular resistance. Higher blood concentrations of local anesthetics may occur due to inadvertent intravascular administration or repeated doses. [40143] (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Bupropion: (Minor) Monitor for an increased incidence of propranolol-related adverse effects if bupropion and propranolol are used concomitantly. Coadministration of bupropion and propranolol may result in increased plasma concentrations of propranolol. Bupropion and hydroxybupropion, the major active metabolite, are inhibitors of CYP2D6 in vitro. Propranolol is a CYP2D6 substrate. [41057] [53617] Bupropion; Naltrexone: (Minor) Monitor for an increased incidence of propranolol-related adverse effects if bupropion and propranolol are used concomitantly. Coadministration of bupropion and propranolol may result in increased plasma concentrations of propranolol. Bupropion and hydroxybupropion, the major active metabolite, are inhibitors of CYP2D6 in vitro. Propranolol is a CYP2D6 substrate. [41057] [53617] Butalbital; Aspirin; Caffeine; Codeine: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Cabergoline: (Moderate) Cabergoline should be used cautiously with antihypertensive agents, including beta-blockers. Cabergoline has been associated with hypotension. Initial doses of cabergoline higher than 1 mg may produce orthostatic hypotension. It may be advisable to monitor blood pressure. [27964] Calcium Carbonate: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Calcium Carbonate; Magnesium Hydroxide: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Calcium Carbonate; Simethicone: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Calcium; Vitamin D: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Canagliflozin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Canagliflozin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Cannabidiol: (Moderate) Use caution when propranolol is administered with cannabidiol due to possible increased propranolol concentrations. Consider a dose reduction of propranolol as clinically appropriate, if adverse reactions occur when administered with cannabidiol. Propranolol is a CYP1A2 substrate and cannabidiol is a weak CYP1A2 inhibitor. [45870] [56853] [63309] Capivasertib: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of capivasertib as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and capivasertib is moderate CYP2D6 inhibitor. [45870] [56853] [69896] Capmatinib: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of capmatinib as concurrent use may increase propranolol exposure. Propranolol is a CYP1A2 substrate and capmatinib is moderate CYP1A2 inhibitor. [45870] [56853] [65377] Carbidopa; Levodopa: (Moderate) Concomitant use of beta-blockers with levodopa can result in additive hypotensive effects. [48681] Carbidopa; Levodopa; Entacapone: (Moderate) Concomitant use of beta-blockers with levodopa can result in additive hypotensive effects. [48681] Cariprazine: (Moderate) Orthostatic vital signs should be monitored in patients who are at risk for hypotension, such as those receiving cariprazine in combination with antihypertensive agents. Atypical antipsychotics may cause orthostatic hypotension and syncope, most commonly during treatment initiation and dosage increases. Patients should be informed about measures to prevent orthostatic hypotension, such as sitting on the edge of the bed for several minutes prior to standing in the morning, or rising slowly from a seated position. Consider a cariprazine dose reduction if hypotension occurs. [60164] Celecoxib: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Celecoxib; Tramadol: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Cenobamate: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of cenobamate as concurrent use may increase propranolol exposure. Propranolol is a CYP2C19 substrate and cenobamate is a moderate CYP2C19 inhibitor. [45870] [56853] [64768] Ceritinib: (Major) Avoid concomitant use of ceritinib with propranolol if possible due to the risk of additive bradycardia. Both ceritinib and propranolol can cause bradycardia. An interruption of ceritinib therapy, dose reduction, or discontinuation of therapy may be necessary if bradycardia occurs. [57094] Cetirizine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Cevimeline: (Major) Cevimeline should be administered with caution to patients taking beta adrenergic antagonists, because of the possibility of conduction disturbances. Cevimeline can potentially alter cardiac conduction and/or heart rate. Patients with significant cardiovascular disease treated with beta-blockers may potentially be unable to compensate for transient changes in hemodynamics or rhythm induced by cevimeline. If use of these drugs together cannot be avoided, close monitoring of blood pressure, heart rate and cardiac function is advised. [48617] Chlophedianol; Dexchlorpheniramine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Chloroprocaine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. [5731] Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Chlorpheniramine; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Chlorpheniramine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Chlorpromazine: (Moderate) Monitor for an increase in chlorpromazine and propranolol-related adverse effects during concomitant use. The concentrations of both medications may increase; concomitant use has been observed to increase propranolol concentrations by 70%, [28997] [56853] Chlorpropamide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] Cholestyramine: (Moderate) Absorption of propranolol may be reduced by concurrent administration with colestipol or cholestyramine. To minimize drug interactions, administer other drugs at least 1 hour before or at least 4 to 6 hours after the administration of cholestyramine. [5057] Choline Salicylate; Magnesium Salicylate: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Ciclesonide: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Cimetidine: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of cimetidine as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and cimetidine is weak CYP2D6 inhibitor. [45870] [50324] [56853] Cinacalcet: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of cinacalcet as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and cinacalcet is moderate CYP2D6 inhibitor. [28126] [28271] [4718] Cisatracurium: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Citalopram: (Minor) Citalopram mildly inhibits the hepatic CYP2D6 isoenzyme at therapeutic doses. This can result in increased concentrations of drugs metabolized via the same pathway, including propranolol. Increased serum levels of the beta-blockers could result in alterations in cardioselectivity or other clinical effects. [28269] [45870] [56853] Clevidipine: (Moderate) Use clevidipine and propranolol with caution due to risk for additive negative effects on heart rate, AV conduction, and/or cardiac contractility. [45870] Clobazam: (Moderate) A dosage reduction of CYP2D6 substrates, such as propranolol, may be necessary during co-administration of clobazam. Limited in vivo data suggest that clobazam is an inhibitor of CYP2D6. If propranolol is used in combination, it is advisable to monitor the patient for adverse reactions related to beta-blockers. [46370] [4718] Clonidine: (Moderate) Monitor heart rate in patients receiving concomitant clonidine and agents known to affect sinus node function or AV nodal conduction (e.g., beta-blockers). Severe bradycardia resulting in hospitalization and pacemaker insertion has been reported during combination therapy with clonidine and other sympatholytic agents. Concomitant use of clonidine with beta-blockers can also cause additive hypotension. Beta-blockers should not be substituted for clonidine when modifications are made in a patient's antihypertensive regimen because beta-blocker administration during clonidine withdrawal can augment clonidine withdrawal, which may lead to a hypertensive crisis. If a beta-blocker is to be substituted for clonidine, clonidine should be gradually tapered and the beta-blocker should be gradually increased over several days to avoid the possibility of rebound hypertension; administration of beta-blockers during withdrawal of clonidine can precipitate severe increases in blood pressure as a result of unopposed alpha stimulation. [28290] [42063] [43663] [60860] Clozapine: (Moderate) Clozapine used concomitantly with the antihypertensive agents can increase the risk and severity of hypotension by potentiating the effect of the antihypertensive drug. [4989] Cobicistat: (Moderate) Coadministration of cobicistat (a CYP2D6 inhibitor) with beta-blockers metabolized by CYP2D6, such as propranolol, may result in elevated beta-blocker serum concentrations. If used concurrently, close clinical monitoring with appropriate beta-blocker dose reductions are advised. [53617] [58000] Cocaine: (Major) Although beta-blockers are indicated to reduce cocaine-induced tachycardia, myocardial ischemia, and arrhythmias, concomitant use of cocaine and non-selective beta-adrenergic blocking agents, including ophthalmic preparations, can cause unopposed alpha-adrenergic activity, resulting in heart block, excessive bradycardia, or hypertension. In theory, the use of alpha-blocker and beta-blocker combinations or selective beta-blockers in low doses may not cause unopposed alpha stimulation in this situation. Labetalol, a beta-blocker with some alpha-blocking activity, has been used successfully to treat cocaine-induced hypertension. In addition, cocaine can reduce the therapeutic effects of beta-blockers. [235] [5053] [6289] Codeine; Guaifenesin; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Codeine; Phenylephrine; Promethazine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Co-Enzyme Q10, Ubiquinone: (Moderate) Co-enzyme Q10, ubiquinone (CoQ10) may lower blood pressure. CoQ10 use in combination with antihypertensive agents may lead to additional reductions in blood pressure in some individuals. Patients who choose to take CoQ10 concurrently with antihypertensive medications should receive periodic blood pressure monitoring. Patients should be advised to inform their prescriber of their use of CoQ10. [34900] Colestipol: (Moderate) Colestipol can bind with and possibly decrease the oral absorption of propranolol. To minimize drug interactions, administer other drugs at least 1 hour before or at least 4 to 6 hours after the administration of colestipol. [4794] [5057] Corticosteroids: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Cortisone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Crizotinib: (Major) Avoid coadministration of crizotinib with agents known to cause bradycardia, such as beta-blockers, to the extent possible due to the risk of additive bradycardia. If concomitant use is unavoidable, monitor heart rate and blood pressure regularly. An interruption of crizotinib therapy or dose adjustment may be necessary if bradycardia occurs. [45458] Dacomitinib: (Moderate) Monitor for increased toxicity of propranolol if coadministered with dacomitinib. Coadministration may increase serum concentrations of propranolol. Propranolol is a CYP2D6 substrate; dacomitinib is a strong CYP2D6 inhibitor. [45870] [56853] [63584] Dapagliflozin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Dapagliflozin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Dapagliflozin; Saxagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Darifenacin: (Moderate) Monitor for increased toxicity of propranolol if coadministered with darifenacin. Coadministration may increase serum concentrations of propranolol. Propranolol is a CYP2D6 substrate; darifenacin is a moderate CYP2D6 inhibitor. [30711] [45870] [56853] Darunavir; Cobicistat: (Moderate) Coadministration of cobicistat (a CYP2D6 inhibitor) with beta-blockers metabolized by CYP2D6, such as propranolol, may result in elevated beta-blocker serum concentrations. If used concurrently, close clinical monitoring with appropriate beta-blocker dose reductions are advised. [53617] [58000] Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: (Moderate) Coadministration of cobicistat (a CYP2D6 inhibitor) with beta-blockers metabolized by CYP2D6, such as propranolol, may result in elevated beta-blocker serum concentrations. If used concurrently, close clinical monitoring with appropriate beta-blocker dose reductions are advised. [53617] [58000] Dasiglucagon: (Minor) A temporary increase in both blood pressure and pulse rate may occur following the administration of glucagon. Patients taking beta-blockers might be expected to have a greater increase in both pulse and blood pressure. Glucagon exerts positive inotropic and chronotropic effects and may, therefore, cause tachycardia and hypertension in some patients. The increase in blood pressure and pulse rate may require therapy in some patients with coronary artery disease. [28627] [29529] Deflazacort: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Delavirdine: (Moderate) Propranolol is significantly metabolized by CYP2D6 isoenzymes and CYP2D6 inhibitors, such as delavirdine, could theoretically impair propranolol metabolism; the clinical significance of such interactions is unknown. [4718] [5206] Desflurane: (Moderate) Concurrent use of beta-blockers with desflurane may result in exaggerated cardiovascular effects (e.g., hypotension and negative inotropic effects). Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. Withdrawal of a beta-blocker perioperatively may be detrimental to the patient's clinical status and is not recommended. Caution is advised if these drugs are administered together. [5054] [56070] Desloratadine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Desvenlafaxine: (Major) Dosage adjustments of some beta-blockers may be necessary during concurrent use of desvenlafaxine. Although clinical studies have shown that desvenlafaxine does not have a clinically relevant effect on CYP2D6 inhibition at doses of 100 mg/day, the manufacturer recommends that primary substrates of CYP2D6, such as propranolol, metoprolol, or nebivolol, be dosed at the original level when co-administered with desvenlafaxine 100 mg or lower or when desvenlafaxine is discontinued. The dose of these CYP2D6 substrates should be reduced by up to one-half if co-administered with desvenlafaxine 400 mg/day. [34940] Dexamethasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Dexbrompheniramine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dexchlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dexmedetomidine: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects. [29112] [67509] Dexmethylphenidate: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dextroamphetamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dextromethorphan; Bupropion: (Minor) Monitor for an increased incidence of propranolol-related adverse effects if bupropion and propranolol are used concomitantly. Coadministration of bupropion and propranolol may result in increased plasma concentrations of propranolol. Bupropion and hydroxybupropion, the major active metabolite, are inhibitors of CYP2D6 in vitro. Propranolol is a CYP2D6 substrate. [41057] [53617] Dextromethorphan; Diphenhydramine; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dextromethorphan; Guaifenesin; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dextromethorphan; Guaifenesin; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dextromethorphan; Quinidine: (Major) Patients receiving combined therapy with quinidine and propranolol should be monitored for potential hypotension, orthostasis, bradycardia and/or AV block and heart failure, Reduce the beta-blocker dosage if necessary. Quinidine may have additive effects (e.g., reduced heart rate, hypotension) on cardiovascular parameters when used together with beta-blockers, such as propranolol. Quinidine is a known inhibitor of CYP2D6, and may additionally impair the hepatic clearance of propanolol (CYP2D6 substrate); patients should be monitored for excess beta-blockade. [28001] [28249] Diazoxide: (Moderate) Additive hypotensive effects can occur with the concomitant administration of diazoxide with other antihypertensive agent. This interaction can be therapeutically advantageous, but dosages must be adjusted accordingly. The manufacturer advises that IV diazoxide should not be administered to patients within 6 hours of receiving beta-blockers. [29537] Diclofenac: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Diclofenac; Misoprostol: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Diethylpropion: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Diflunisal: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Digoxin: (Moderate) Monitor heart rate during concomitant digoxin and propranolol use due to increased risk for bradycardia. Both digoxin and propranolol slow atrioventricular conduction (AV) and decrease heart rate; additive effects on AV node conduction can result in bradycardia and advanced or complete heart block. [28271] [28272] [45870] Dihydroergotamine: (Moderate) Monitor for an increase in the incidence and severity of vasospastic adverse reactions including cerebral and peripheral ischemia during concomitant use of ergotamine and propranolol. Propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating properties of epinephrine. [28852] [66964] Diltiazem: (Major) Intravenous propranolol is contraindicated with intravenous diltiazem use in close proximity (within a few hours). Fatal cardiac arrests have occurred in patients receiving intravenous beta-blockers and intravenous calcium channel blockers. Use oral propranolol and oral diltiazem with caution due to risk for additive negative effects on heart rate, AV conduction, and/or cardiac contractility. If combination therapy is initiated or withdrawn in conjunction with propranolol, an adjustment in the propranolol dose may be warranted. Administration of diltiazem concomitantly with propranolol in 5 normal volunteers resulted in increased propranolol concentrations in all subjects, and bioavailability of propranolol was increased approximately 50%. In vitro, propranolol appears to be displaced from its binding sites by diltiazem. [45688] [45870] [55768] Dipeptidyl Peptidase-4 Inhibitors: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Diphenhydramine; Ibuprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Diphenhydramine; Naproxen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Diphenhydramine; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Dipyridamole: (Major) Beta-blockers should generally be withheld before dipyridamole-stress testing. Monitor the heart rate carefully following the dipyridamole injection. [32916] Disopyramide: (Major) Because the pharmacologic effects of propranolol include AV nodal conduction depression and negative inotropy, additive effects are possible when used in combination with disopyramide. Propranolol has occasionally been used with disopyramide; however, the manufacturer states that the concomitant use of disopyramide with propranolol should be reserved for patients with refractory life-threatening arrhythmias. Such use may produce serious negative inotropic effects, or may excessively prolong conduction. In healthy subjects, no significant drug interaction has been observed when propranolol is coadministered with disopyramide. [28228] [28271] [53617] Dobutamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Donepezil: (Moderate) The increase in vagal tone induced by some cholinesterase inhibitors may produce bradycardia, hypotension, or syncope. The vagotonic effect of these drugs may be increased when given with other medications known to cause bradycardia such as beta-blockers. These interactions are pharmacodynamic in nature rather than pharmacokinetic. [30948] Donepezil; Memantine: (Moderate) The increase in vagal tone induced by some cholinesterase inhibitors may produce bradycardia, hypotension, or syncope. The vagotonic effect of these drugs may be increased when given with other medications known to cause bradycardia such as beta-blockers. These interactions are pharmacodynamic in nature rather than pharmacokinetic. [30948] Dopamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Doxapram: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Doxazosin: (Moderate) Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. [30211] Dronedarone: (Major) In dronedarone clinical trials, bradycardia was seen more frequently in patients also receiving beta blockers. If coadministration of dronedarone and a beta blocker is unavoidable, administer a low dose of the beta blocker initially and increase the dosage only after ECG verification of tolerability. Concomitant administration may decreased AV and sinus node conduction. Furthermore, dronedarone is an inhibitor of CYP2D6, and some beta blockers are substrates for CYP2D6 (e.g., metoprolol, propranolol, nebivolol, carvedilol). Coadministration of dronedarone with a single dose of propranolol and multiple doses of metoprolol increased propranolol and metoprolol exposure by 1.3- and 1.6-fold, respectively. [36101] [60860] Dulaglutide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Duloxetine: (Moderate) Monitor blood pressure during concomitant duloxetine and propranolol use. Concomitant use increases the risk for hypotension, including orthostatic hypotension and syncope. Consider reducing the duloxetine dose or discontinuing duloxetine if symptomatic orthostatic hypotension, falls, or syncope occur during treatment. [29934] Dutasteride; Tamsulosin: (Minor) Tamsulosin did not potentiate the hypotensive effects of atenolol. However, since the symptoms of orthostasis are reported more frequently in tamsulosin-treated vs. placebo patients, there is a potential risk of enhanced hypotensive effects when co-administered with antihypertensive agents. [29677] Eletriptan: (Minor) Periodically monitor blood pressure in patients who regularly use eletriptan and are taking propranolol. Monitor for the rare patient who might experience an increase in dose-related side effects of eletriptan, such as nausea, dizziness, and drowsiness. No dosage adjustment appears to be needed for eletriptan. The Cmax and AUC of eletriptan were increased by 10 and 33%, respectively, in the presence of propranolol. No interactive increases in blood pressure were observed. The interaction should not be significant for most patients. [29121] Eliglustat: (Moderate) Coadministration of propranolol and eliglustat may result in increased plasma concentrations of propranolol. Consider reducing the propranolol dosage and titrating to clinical effect. Propranolol is a CYP2D6 and P-glycoprotein (P-gp) substrate; eliglustat is a CYP2D6 and P-gp inhibitor. [53617] [57803] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Moderate) Coadministration of cobicistat (a CYP2D6 inhibitor) with beta-blockers metabolized by CYP2D6, such as propranolol, may result in elevated beta-blocker serum concentrations. If used concurrently, close clinical monitoring with appropriate beta-blocker dose reductions are advised. [53617] [58000] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Coadministration of cobicistat (a CYP2D6 inhibitor) with beta-blockers metabolized by CYP2D6, such as propranolol, may result in elevated beta-blocker serum concentrations. If used concurrently, close clinical monitoring with appropriate beta-blocker dose reductions are advised. [53617] [58000] Empagliflozin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Empagliflozin; Linagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Empagliflozin; Linagliptin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Empagliflozin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Enasidenib: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of enasidenib as concurrent use may increase propranolol exposure. Propranolol is a CYP1A2 and CYP2D6 substrate and enasidenib is a strong CYP1A2 and weak CYP2D6 inhibitor. [45870] [56853] [62181] Ephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Ephedrine; Guaifenesin: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Epinephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Epoprostenol: (Moderate) Epoprostenol can have additive effects when administered with other antihypertensive agents, including beta-blockers. These effects can be used to therapeutic advantage, but dosage adjustments may be necessary. [5558] Ergotamine: (Moderate) Monitor for an increase in the incidence and severity of vasospastic adverse reactions including cerebral and peripheral ischemia during concomitant use of ergotamine and propranolol. Propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating properties of epinephrine. [28852] [66964] Ergotamine; Caffeine: (Moderate) Monitor for an increase in the incidence and severity of vasospastic adverse reactions including cerebral and peripheral ischemia during concomitant use of ergotamine and propranolol. Propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating properties of epinephrine. [28852] [66964] Ertugliflozin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Ertugliflozin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Ertugliflozin; Sitagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Escitalopram: (Minor) Escitalopram modestly inhibits the hepatic CYP2D6 isoenzyme. This can result in increased concentrations of drugs metabolized via the same pathway, including propranolol. Increased serum levels of the beta-blockers could result in reductions in cardioselectivity. [4718] Estradiol: (Minor) Estrogens can induce fluid retention and may increase blood pressure in some patients; patients who are receiving antihypertensive agents concurrently with hormonal contraceptives should be monitored for antihypertensive effectiveness. [805] Ethiodized Oil: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Etodolac: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Etomidate: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. [28325] Etrasimod: (Moderate) Monitor heart rate if concomitant use of etrasimod and a beta-blocker is necessary. Transient decreases in heart rate and AV conduction delays have been observed with etrasimod therapy which may increase the risk for bradycardia. The risk for harm may be greatest if a beta-blocker is added to a stable etrasimod regimen. [69114] Everolimus: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of everolimus as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and everolimus is a CYP2D6 inhibitor. [45870] [49823] [49903] [56853] Exenatide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Ezetimibe; Simvastatin: (Minor) After administration of single doses of simvastatin and propranolol, there was a significant decrease in mean Cmax, with no change in AUC, of simvastatin. The clinical significance of this interaction is unknown. Monitor for potential reduced cholesterol-lowering efficacy when propranolol is coadministered with niacin; simvastatin. [10709] Fedratinib: (Moderate) Monitor for increased propranolol adverse reactions including bradycardia and hypotension during coadministration of fedratinib. Propranolol exposure may increase. Fedratinib is a moderate CYP2D6 and CYP2C19 inhibitor and propranolol is a CYP2D6 and CYP2C19 substrate. [45870] [56853] [64568] Fenofibric Acid: (Minor) At therapeutic concentrations, fenofibric acid is a weak inhibitor of CYP2C19. Concomitant use of fenofibric acid with CYP2C19 substrates, such as propranolol, has not been formally studied. Fenofibric acid may theoretically increase plasma concentrations of CYP2C19 substrates and could lead to toxicity for drugs that have a narrow therapeutic range. Monitor the therapeutic effect of propranolol during coadministration with fenofibric acid. [49952] [4998] Fenoldopam: (Major) Avoid concomitant use of fenoldopam with beta-blockers due to the risk of hypotension. If used together, monitor blood pressure frequently. Beta-blockers may inhibit the sympathetic reflex response to fenoldopam. [28947] Fenoprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Fexinidazole: (Major) Avoid concomitant use of fexinidazole and medications that cause bradycardia, such as beta-blockers, especially in patients with additional risk factors for torsade de pointes (TdP). Coadministration may increase the risk of QT/QTc prolongation and TdP. Fexinidazole is known to prolong the QT interval and medications that may cause bradycardia can increase the risk for TdP in patients with a prolonged QT/QTc interval. [66812] Fexofenadine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Fingolimod: (Major) If possible, do not start fingolimod in a patient who is taking a drug that slows the heart rate or atrioventricular conduction such as beta-blockers. Use of these drugs during fingolimod initiation may be associated with severe bradycardia or heart block. Seek advice from the prescribing physician regarding the possibility to switch to drugs that do not slow the heart rate or atrioventricular conduction before initiating fingolimod. After the first fingolimod dose, overnight monitoring with continuous ECG in a medical facility is advised for patients who cannot stop taking drugs that slow the heart rate or atrioventricular conduction. Experience with fingolimod in patients receiving concurrent therapy with drugs that slow the heart rate or atrioventricular conduction is limited. [41823] Fish Oil, Omega-3 Fatty Acids (Dietary Supplements): (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents. [30536] [30537] [30538] [30539] [30540] Flecainide: (Moderate) Monitor heart rate during concomitant flecainide and propranolol use due to risk for additive negative inotropic effects. [28271] [28289] Fludrocortisone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Flunisolide: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Fluorescein: (Moderate) Patients on beta-blockers are at an increased risk of adverse reaction when administered fluorescein injection. It is thought that beta-blockers may worsen anaphylaxis severity by exacerbating bronchospasm or by increasing the release of anaphylaxis mediators; alternately, beta-blocker therapy may make the patient more pharmacodynamically resistance to epinephrine rescue treatment. [32841] [32843] Fluoxetine: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of fluoxetine as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and fluoxetine is a moderate CYP2D6 inhibitor. [32061] [32062] [44058] [45870] [53347] [56853] Flurbiprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Fluticasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Fluticasone; Salmeterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Fluticasone; Umeclidinium; Vilanterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Fluticasone; Vilanterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Fluvoxamine: (Moderate) Fluvoxamine can also inhibit hepatic cytochrome P-450 isoenzymes and has been shown to interfere with propranolol clearance however clinical symptoms of excessive beta-blocker effects were not seen. [5943] Food: (Major) Advise patients to avoid cannabis use during propranolol treatment due to decreased exposure of propranolol which may alter its efficacy. Cannabis use induces CYP1A2 and propranolol is a CYP1A2 substrate. The induction potential of cannabis is greatest with chronic inhalation. Other routes of administration or sporadic use may have less of an effect. [28271] [67472] [67473] [67474] Formoterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Formoterol; Mometasone: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Fosphenytoin: (Minor) Phenytoin has been shown to accelerate the hepatic metabolism of propranolol. Because fosphenytoin is metabolized to phenytoin, fosphenytoin will most likely also accelerate the hepatic metabolism of propranolol. [4998] [5265] Gabapentin: (Minor) The combination of propranolol and gabapentin may induce dystonia via a pharmacodynamic interaction. [26512] Galantamine: (Moderate) The increase in vagal tone induced by cholinesterase inhibitors, such as galantamine, may produce bradycardia or syncope. The vagotonic effect of galantamine may theoretically be increased when given with beta-blockers. [62457] General anesthetics: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. [28325] Ginger, Zingiber officinale: (Minor) In vitro studies have demonstrated the positive inotropic effects of certain gingerol constituents of ginger; but it is unclear if whole ginger root exhibits these effects clinically in humans. It is theoretically possible that excessive doses of ginger could affect the action of inotropes; however, no clinical data are available. [25572] Glimepiride: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] Glipizide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] Glipizide; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Glucagon: (Minor) A temporary increase in both blood pressure and pulse rate may occur following the administration of glucagon. Patients taking beta-blockers might be expected to have a greater increase in both pulse and blood pressure. Glucagon exerts positive inotropic and chronotropic effects and may, therefore, cause tachycardia and hypertension in some patients. The increase in blood pressure and pulse rate may require therapy in some patients with coronary artery disease. [28627] [29529] Glyburide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] Glyburide; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Glycopyrrolate; Formoterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Guaifenesin; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Guaifenesin; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Guanfacine: (Moderate) Guanfacine can have additive effects when administered with other antihypertensive agents, including beta-blockers. These effects can be used to therapeutic advantage, but dosage adjustments may be necessary. [6133] Haloperidol: (Moderate) Haloperidol should be used cautiously with propranolol due to the possibility of additive hypotension and increased concentrations of propranolol. Propranolol is significantly metabolized by CYP2D6 isoenzymes. A case report of 3 severe hypotension episodes (2 requiring cardiopulmonary resuscitation) has been reported in one 48 year old woman when propranolol and haloperidol have been coadministered. Additive hypotensive effects and haloperidol-mediated CYP2D6 inhibition may have contributed to this interaction. [27653] [28307] Hydralazine; Isosorbide Dinitrate, ISDN: (Moderate) Nitroglycerin can cause hypotension. This action may be additive with other agents that can cause hypotension such as antihypertensive agents or other peripheral vasodilators. Patients should be monitored more closely for hypotension if nitroglycerin, including nitroglycerin rectal ointment, is used concurrently with any beta-blockers. [29386] [45135] Hydrocodone; Ibuprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Hydrocodone; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Hydrocortisone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Ibuprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Ibuprofen; Famotidine: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Ibuprofen; Oxycodone: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Ibuprofen; Pseudoephedrine: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Icosapent ethyl: (Moderate) Beta-blockers may exacerbate hypertriglyceridemia and should be discontinued or changed to alternate therapy, if possible, prior to initiation of icosapent ethyl. [51323] Iloperidone: (Moderate) Secondary to alpha-blockade, iloperidone can produce vasodilation that may result in additive effects during concurrent use with antihypertensive agents. The potential reduction in blood pressure can precipitate orthostatic hypotension and associated dizziness, tachycardia, and syncope. If concurrent use of iloperidone and antihypertensive agents is necessary, patients should be counseled on measures to prevent orthostatic hypotension, such as sitting on the edge of the bed for several minutes prior to standing in the morning and rising slowly from a seated position. Close monitoring of blood pressure is recommended until the full effects of the combination therapy are known. [36146] Iloprost: (Moderate) Additive reductions in blood pressure may occur when inhaled iloprost is administered to patients receiving other antihypertensive agents. [30774] Imatinib: (Moderate) Propranolol is significantly metabolized by CYP2D6 isoenzymes. CYP2D6 inhibitors, such as imatinib, could theoretically impair propranolol metabolism; the clinical significance of such interactions is unknown. [4718] Incretin Mimetics: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Indacaterol; Glycopyrrolate: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Indocyanine Green: (Minor) In a study of 9 healthy adults given 0.5 mg/kg of indocyanine green, propranolol decreased clearance by 21%. [49708] [49709] Indomethacin: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Insulin Aspart: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Aspart; Insulin Aspart Protamine: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Degludec: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Degludec; Liraglutide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Detemir: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Glargine: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Glargine; Lixisenatide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Glulisine: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Lispro: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin Lispro; Insulin Lispro Protamine: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulin, Inhaled: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Insulins: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Intravenous Lipid Emulsions: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents. [30536] [30537] [30538] [30539] [30540] Iobenguane I 131: (Major) Discontinue propranolol for at least 5 half-lives before the administration of the dosimetry dose or a therapeutic dose of iobenguane I-131. Do not restart propranolol until at least 7 days after each iobenguane I-131 dose. Drugs that reduce catecholamine uptake or deplete catecholamine stores, such as propranolol, may interfere with iobenguane I-131 uptake into cells and interfere with dosimetry calculations resulting in altered iobenguane I-131 efficacy. [63402] Iodixanol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Iohexol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Iomeprol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Iopamidol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Iopromide: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Ioversol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Ipratropium; Albuterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Isocarboxazid: (Moderate) Additive hypotensive effects may be seen when monoamine oxidase inhibitors (MAOIs) are combined with antihypertensives. Careful monitoring of blood pressure is suggested during concurrent therapy of MAOIs with beta-blockers. Limited data suggest that bradycardia is worsened when MAOIs are administered to patients receiving beta-blockers. Although the sinus bradycardia observed was not severe, until more data are available, clinicians should use MAOIs cautiously in patients receiving beta-blockers. Patients should be instructed to rise slowly from a sitting position, and to report syncope or changes in blood pressure or heart rate to their health care provider. [4673] [5055] [6398] Isoflurane: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. [28325] Isoniazid, INH; Pyrazinamide, PZA; Rifampin: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Isoniazid, INH; Rifampin: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Isophane Insulin (NPH): (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Isoproterenol: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Isosorbide Dinitrate, ISDN: (Moderate) Nitroglycerin can cause hypotension. This action may be additive with other agents that can cause hypotension such as antihypertensive agents or other peripheral vasodilators. Patients should be monitored more closely for hypotension if nitroglycerin, including nitroglycerin rectal ointment, is used concurrently with any beta-blockers. [29386] [45135] Isosorbide Mononitrate: (Moderate) Nitroglycerin can cause hypotension. This action may be additive with other agents that can cause hypotension such as antihypertensive agents or other peripheral vasodilators. Patients should be monitored more closely for hypotension if nitroglycerin, including nitroglycerin rectal ointment, is used concurrently with any beta-blockers. [29386] [45135] Isosulfan Blue: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Isradipine: (Moderate) Although concomitant therapy with beta-blockers and isradipine is generally well tolerated and can even be beneficial in some cases, coadministration of these agents can induce excessive bradycardia or hypotension. Isradipine when used in combination with beta-blockers, especially in heart failure patients, can result in additive negative inotropic effects. Finally, angina has been reported when beta-adrenergic blocking agents are withdrawn abruptly when isradipine therapy is initiated. A gradual downward titration of the beta-adrenergic blocking agent dosage during initiation of isradipine therapy can minimize or eliminate this potential interaction. Patients should be monitored carefully, however, for excessive bradycardia, cardiac conduction abnormalities, or hypotension when these drugs are given together. In general, these reactions are more likely to occur with other non-dihydropyridine calcium channel blockers than with isradipine. [29128] Ivabradine: (Moderate) Monitor heart rate if ivabradine is coadministered with other negative chronotropes like beta-blockers. Most patients receiving ivabradine will receive concomitant beta-blocker therapy. Coadministration of drugs that slow heart rate increases the risk for bradycardia. [59430] Ketamine: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. [28325] Ketoprofen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Ketorolac: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Lacosamide: (Moderate) Use lacosamide with caution in patients taking concomitant medications that affect cardiac conduction, such as beta-blockers, because of the risk of AV block, bradycardia, or ventricular tachyarrhythmia. If use together is necessary, obtain an ECG prior to lacosamide initiation and after treatment has been titrated to steady-state. In addition, monitor patients receiving lacosamide via the intravenous route closely. [34626] Lanreotide: (Moderate) Concomitant administration of bradycardia-inducing drugs (e.g., beta-adrenergic blockers) may have an additive effect on the reduction of heart rate associated with lanreotide. Adjust the beta-blocker dose if necessary. [33519] Lasmiditan: (Moderate) Monitor heart rate if lasmiditan is coadministered with beta-blockers as concurrent use may increase the risk for bradycardia. Lasmiditan has been associated with lowering of heart rate. In a drug interaction study, addition of a single 200 mg dose of lasmiditan to a beta-blocker (propranolol) decreased heart rate by an additional 5 beats per minute. [64685] Levalbuterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Levamlodipine: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Levodopa: (Moderate) Concomitant use of beta-blockers with levodopa can result in additive hypotensive effects. [48681] Levothyroxine: (Minor) Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones. The reduction of effects may be especially evident when a patient goes from a hypothyroid to a euthyroid state or when excessive amounts of thyroid hormone is given to the patient. [29527] [43942] Levothyroxine; Liothyronine (Porcine): (Minor) Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones. The reduction of effects may be especially evident when a patient goes from a hypothyroid to a euthyroid state or when excessive amounts of thyroid hormone is given to the patient. [29527] [43942] Levothyroxine; Liothyronine (Synthetic): (Minor) Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones. The reduction of effects may be especially evident when a patient goes from a hypothyroid to a euthyroid state or when excessive amounts of thyroid hormone is given to the patient. [29527] [43942] Lidocaine: (Major) Drugs such as beta-blockers that decrease cardiac output reduce hepatic blood flow and thereby decrease lidocaine hepatic clearance. Also, opposing effects on conduction exist between lidocaine and beta-blockers while their effects to decrease automaticity may be additive. Propranolol has been shown to decrease lidocaine clearance and symptoms of lidocaine toxicity have been seen as a result of this interaction. This interaction is possible with other beta-blocking agents since most decrease hepatic blood flow. Monitoring of lidocaine concentrations is recommended during concomitant therapy with beta-blockers. [40143] [5001] Lidocaine; Epinephrine: (Major) Drugs such as beta-blockers that decrease cardiac output reduce hepatic blood flow and thereby decrease lidocaine hepatic clearance. Also, opposing effects on conduction exist between lidocaine and beta-blockers while their effects to decrease automaticity may be additive. Propranolol has been shown to decrease lidocaine clearance and symptoms of lidocaine toxicity have been seen as a result of this interaction. This interaction is possible with other beta-blocking agents since most decrease hepatic blood flow. Monitoring of lidocaine concentrations is recommended during concomitant therapy with beta-blockers. [40143] [5001] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Lidocaine; Prilocaine: (Major) Drugs such as beta-blockers that decrease cardiac output reduce hepatic blood flow and thereby decrease lidocaine hepatic clearance. Also, opposing effects on conduction exist between lidocaine and beta-blockers while their effects to decrease automaticity may be additive. Propranolol has been shown to decrease lidocaine clearance and symptoms of lidocaine toxicity have been seen as a result of this interaction. This interaction is possible with other beta-blocking agents since most decrease hepatic blood flow. Monitoring of lidocaine concentrations is recommended during concomitant therapy with beta-blockers. [40143] [5001] (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. [5731] [5815] Linagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Linagliptin; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Linezolid: (Moderate) Linezolid is an antibiotic that is also a reversible, non-selective MAO inhibitor. Bradycardia may be worsened when MAO-inhibitors are co-administered to patients receiving beta-blockers. Use linezolid cautiously in patients receiving beta-blockers. [5330] Liothyronine: (Minor) Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones. The reduction of effects may be especially evident when a patient goes from a hypothyroid to a euthyroid state or when excessive amounts of thyroid hormone is given to the patient. [29527] [43942] Liraglutide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Lisdexamfetamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Lixisenatide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Lofexidine: (Major) Because both lofexidine and propranolol can cause hypotension and bradycardia, concurrent use should be avoided if possible. Patients being given lofexidine in an outpatient setting should be capable of and instructed on self-monitoring for hypotension, orthostasis, bradycardia, and associated symptoms. If clinically significant or symptomatic hypotension and/or bradycardia occur, the next dose of lofexidine should be reduced in amount, delayed, or skipped. [63161] Lonafarnib: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of lonafarnib as concurrent use may increase propranolol exposure. Propranolol is a CYP2C19 substrate and lonafarnib is a moderate CYP2C19 inhibitor. [45870] [56853] [66129] Lopinavir; Ritonavir: (Moderate) Concurrent administration of propranolol with ritonavir may result in elevated propranolol plasma concentrations. Cardiac and neurologic events have been reported when ritonavir is concurrently administered with beta-blockers. Propranolol is metabolized by the hepatic isoenzyme CYP2D6; ritonavir is an inhibitor of this enzyme. Caution and close monitoring are advised if these drugs are administered together. Decreased beta-blocker dosage may be needed. [28315] [47165] [4998] [58664] Loratadine; Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Lumacaftor; Ivacaftor: (Minor) Concomitant use of propranolol and lumacaftor; ivacaftor may decrease the systemic exposure of propranolol; caution and monitoring of blood pressure and other therapeutic effects are advised if these drugs are used together. Propranolol is partially metabolized by CYP2C19; in vitro data suggest that lumacaftor may induce CYP2C19. [45870] [56853] [59891] Lumacaftor; Ivacaftor: (Minor) Concomitant use of propranolol and lumacaftor; ivacaftor may decrease the systemic exposure of propranolol; caution and monitoring of blood pressure and other therapeutic effects are advised if these drugs are used together. Propranolol is partially metabolized by CYP2C19; in vitro data suggest that lumacaftor may induce CYP2C19. [45870] [56853] [59891] Lurasidone: (Moderate) Due to the antagonism of lurasidone at alpha-1 adrenergic receptors, the drug may enhance the hypotensive effects of alpha-blockers and other antihypertensive agents. If concurrent use of lurasidone and antihypertensive agents is necessary, patients should be counseled on measures to prevent orthostatic hypotension, such as sitting on the edge of the bed for several minutes prior to standing in the morning and rising slowly from a seated position. Close monitoring of blood pressure is recommended until the full effects of the combination therapy are known. [42227] Magnesium Hydroxide: (Moderate) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [28271] Magnesium Salicylate: (Moderate) Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Mavacamten: (Moderate) Expect additive negative inotropic effects during concomitant use of mavacamten and beta-blockers. If concomitant therapy with beta-blockers is initiated, or if the dose is increased, monitor left ventricular ejection fraction closely until stable doses and clinical response have been achieved. Avoid concomitant use of mavacamten and a beta-blocker plus verapamil or diltiazem due to an increased risk of left ventricular systolic dysfunction and heart failure symptoms. [67543] Meclofenamate Sodium: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Mefenamic Acid: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Mefloquine: (Major) Concurrent use of mefloquine and beta blockers can result in ECG abnormalities or cardiac arrest. [28301] Meglitinides: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Meloxicam: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Mepivacaine: (Major) Propranolol has been shown to significantly decrease the clearance of the amide local anesthetics (e.g., lidocaine, bupivacaine, and mepivacaine). Lidocaine and bupivacaine toxicity have been reported after coadministration with propranolol. The mechanism of the interaction between propranolol and lidocaine is thought to be due to propranolol-induced decreased hepatic blood flow causing decreased elimination of lidocaine. [40143] Metaproterenol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Metformin; Repaglinide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Metformin; Saxagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Metformin; Sitagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Methacholine: (Moderate) Beta-blockers may impair reversal of methacholine-induced bronchoconstriction with an inhaled rapid-acting beta-agonist. [43792] Methamphetamine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Methimazole: (Minor) Hyperthyroidism may cause increased clearance of beta blockers that possess a high extraction ratio. A dose reduction of some beta-blockers may be needed when a hyperthyroid patient treated with methimazole becomes euthyroid. [5176] Methohexital: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. [28325] Methylergonovine: (Moderate) Monitor for an increase in the incidence and severity of vasospastic adverse reactions, including cerebral and peripheral ischemia, during concomitant use of methylergonovine and beta-blockers. Beta-blockers may potentiate the vasoconstrictive actions of methylergonovine. [48893] Methylphenidate: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Methylprednisolone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Mexiletine: (Moderate) Mexiletine has been found to increase propranolol concentrations in patients receiving concomitant therapy. The significance of the elevated propranolol concentration is not known as beta-blockers have a wide therapeutic range. It may be prudent to monitor patients for adverse effects when mexiletine are combined with propranolol. [5028] [5029] Midodrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Miglitol: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Milrinone: (Moderate) Concurrent administration of antihypertensive agents could lead to additive hypotension when administered with milrinone. Titrate milrinone dosage according to hemodynamic response. [7629] Mirabegron: (Moderate) Mirabegron is a moderate CYP2D6 inhibitor. Exposure of drugs metabolized by CYP2D6 such as propranolol may be increased when co-administered with mirabegron. Propranolol is primarily metabolized by CYP2D6. Therefore, appropriate monitoring and dose adjustment may be necessary. [45870] [51111] [56853] Modafinil: (Moderate) In vitro data indicate that modafinil is an inhibitor of CYP2C19. In theory, dosage reductions may be required for drugs that are largely eliminated via CYP2C19 metabolism such as propranolol during coadministration with modafinil. [41243] Mometasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Nabumetone: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Naproxen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Naproxen; Esomeprazole: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Naproxen; Pseudoephedrine: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Nateglinide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Nefazodone: (Minor) Although relatively infrequent, nefazodone may cause orthostatic hypotension in some patients; this effect may be additive with antihypertensive agents. Blood pressure monitoring and dosage adjustments of either drug may be necessary. [5414] Nesiritide, BNP: (Major) The potential for hypotension may be increased when coadministering nesiritide with antihypertensive agents. [29061] Neuromuscular blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Niacin, Niacinamide: (Moderate) Cutaneous vasodilation induced by niacin may become problematic if high-dose niacin is used concomitantly with other antihypertensive agents. This effect is of particular concern in the setting of acute myocardial infarction, unstable angina, or other acute hemodynamic compromise. [44027] Nicardipine: (Moderate) Use propranolol and nicardipine with caution due to risk for additive negative effects on heart rate, AV conduction, and/or cardiac contractility. The mean Cmax and AUC of propranolol are increased by 80% and 47%, respectively, by coadministration of nicardipine. [45870] NIFEdipine: (Moderate) In general, concomitant therapy of nifedipine with beta-blockers is well tolerated and can even be beneficial in some cases (i.e., inhibition of nifedipine-induced reflex tachycardia by beta-blockade). Negative inotropic and/or chronotropic effects can be additive when these drugs are used in combination. Finally, angina has been reported when beta-adrenergic blocking agents are withdrawn abruptly and nifedipine therapy is initiated. A gradual downward titration of the beta-adrenergic blocking agent dosage during initiation of nifedipine therapy may minimize or eliminate this potential interaction. Hypotension and impaired cardiac performance can occur during coadministration of nifedipine with beta-blockers, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. Monitor clinical response during coadministration; adjustment of nifedipine dosage may be needed during concurrent beta-blocker therapy. [29068] [31749] Nimodipine: (Moderate) Nimodipine, a selective calcium-channel blocker, can enhance the antihypertensive effects of beta-blockers. Although often used together, concurrent use of calcium-channel blockers and beta-blockers may result in additive hypotensive, negative inotropic, and/or bradycardic effects in some patients. [29082] Niraparib; Abiraterone: (Moderate) Monitor blood pressure and heart rate if coadministration of propranolol with abiraterone is necessary. Propranolol is a CYP2D6 substrate and abiraterone is a CYP2D6 inhibitor. Concomitant use may result in hypotension and bradycardia. [44156] [45870] [56853] Nirmatrelvir; Ritonavir: (Moderate) Concurrent administration of propranolol with ritonavir may result in elevated propranolol plasma concentrations. Cardiac and neurologic events have been reported when ritonavir is concurrently administered with beta-blockers. Propranolol is metabolized by the hepatic isoenzyme CYP2D6; ritonavir is an inhibitor of this enzyme. Caution and close monitoring are advised if these drugs are administered together. Decreased beta-blocker dosage may be needed. [28315] [47165] [4998] [58664] Nisoldipine: (Moderate) Concurrent use of nisoldipine with propranolol can be beneficial (i.e., inhibition of vasodilation-induced reflex tachycardia by beta-blockade); however, the additive negative inotropic and/or chronotropic effects can cause adverse effects, especially in patients with compromised ventricular function or conduction defects (e.g., sinus bradycardia or AV block). Pharmacokinetic interactions between nisoldipine and propranolol are variable and not significant. Propranolol attenuated the heart rate increase following the administration of immediate release nisoldipine. [29088] Nitrates: (Moderate) Nitroglycerin can cause hypotension. This action may be additive with other agents that can cause hypotension such as antihypertensive agents or other peripheral vasodilators. Patients should be monitored more closely for hypotension if nitroglycerin, including nitroglycerin rectal ointment, is used concurrently with any beta-blockers. [29386] [45135] Nitroglycerin: (Moderate) Nitroglycerin can cause hypotension. This action may be additive with other agents that can cause hypotension such as antihypertensive agents or other peripheral vasodilators. Patients should be monitored more closely for hypotension if nitroglycerin, including nitroglycerin rectal ointment, is used concurrently with any beta-blockers. [29386] [45135] Nitroprusside: (Moderate) Additive hypotensive effects may occur when nitroprusside is used concomitantly with other antihypertensive agents. Dosages should be adjusted carefully, according to blood pressure. [29571] Non-Ionic Contrast Media: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine. [28963] [49612] Nonsteroidal antiinflammatory drugs: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Norepinephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Octreotide: (Moderate) Monitor for bradycardia during concomitant use of beta-blockers and octreotide and adjust drug dosage based on response as appropriate. Both medications may cause bradycardia and concomitant use may increase bradycardia risk. [29113] [51310] [65637] Olanzapine: (Moderate) Olanzapine may induce orthostatic hypotension and thus enhance the effects of antihypertensive agents. [5517] Olanzapine; Fluoxetine: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of fluoxetine as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and fluoxetine is a moderate CYP2D6 inhibitor. [32061] [32062] [44058] [45870] [53347] [56853] (Moderate) Olanzapine may induce orthostatic hypotension and thus enhance the effects of antihypertensive agents. [5517] Olanzapine; Samidorphan: (Moderate) Olanzapine may induce orthostatic hypotension and thus enhance the effects of antihypertensive agents. [5517] Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Olodaterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Olopatadine; Mometasone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Omeprazole; Amoxicillin; Rifabutin: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Omeprazole; Sodium Bicarbonate: (Major) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [4498] Oritavancin: (Moderate) Propranolol is metabolized by CYP2C19 and CYP2D6; oritavancin is a weak inhibitor of CYP2C19 and a weak CYP2D6 inducer. Coadministration may result in altered propranolol plasma concentrations. If these drugs are administered concurrently, blood pressure should be monitored closely. [4998] [57741] Osilodrostat: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of osilodrostat as concurrent use may increase propranolol exposure. Propranolol is a CYP1A2 substrate and osilodrostat is a moderate CYP1A2 inhibitor. [45870] [56853] [65098] Oxaprozin: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Oxymetazoline: (Major) The vasoconstricting actions of oxymetazoline, an alpha adrenergic agonist, may reduce the antihypertensive effects produced by beta-blockers. If these drugs are used together, closely monitor for changes in blood pressure. [26181] [61733] Ozanimod: (Moderate) Ozanimod may cause bradycardia and AV-conduction delays, which may be enhanced with the concomitant use of beta-blockers. If a calcium channel blocker that slows heart rate/cardiac conduction is also prescribed with ozanimod and a beta-blocker, a cardiologist should be consulted due to the likelyhood of additive effects. [65169] Paliperidone: (Moderate) Paliperidone may cause orthostatic hypotension, thereby enhancing the hypotensive effects of antihypertensive agents. Orthostatic vital signs should be monitored in patients receiving paliperidone and beta-adrenergic blockers who are susceptible to hypotension. [32936] [40936] Pancuronium: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Paroxetine: (Minor) Paroxetine impairs metabolism of the hepatic CYP2D6 isoenzyme pathway at therapeutic doses, resulting in substantial increases in concentrations of other drugs metabolized via the same pathway, including propranolol. Clinicians should use paroxetine cautiously with propranolol; downward dose adjustments of the beta-blocker may be required if paroxetine is initiated; alternatively an upward dose adjustment of the beta blocker may be needed if paroxetine is discontinued. Patients should be advised to report increased effects of these medications, including hypotension or increased dizziness to their health care professional. [4718] Pasireotide: (Major) Pasireotide may cause a decrease in heart rate. Closely monitor patients who are also taking drugs associated with bradycardia such as beta-blockers. Dose adjustments of beta-blockers may be necessary. [52611] Peginterferon Alfa-2b: (Moderate) Monitor for adverse effects associated with increased exposure to propranolol if peginterferon alfa-2b is coadministered. Peginterferon alfa-2b is a CYP2D6 inhibitor, while propranolol is a CYP2D6 substrate. [29627] [43887] [53617] Pentoxifylline: (Moderate) Pentoxifylline has been used concurrently with antihypertensive drugs (beta blockers, diuretics) without observed problems. Small decreases in blood pressure have been observed in some patients treated with pentoxifylline; periodic systemic blood pressure monitoring is recommended for patients receiving concomitant antihypertensives. If indicated, dosage of the antihypertensive agents should be reduced. [6316] Perindopril; Amlodipine: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Perphenazine: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of perphenazine as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and perphenazine is weak CYP2D6 inhibitor. [45870] [56853] [68137] Perphenazine; Amitriptyline: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of perphenazine as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 substrate and perphenazine is weak CYP2D6 inhibitor. [45870] [56853] [68137] Phendimetrazine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Phenelzine: (Moderate) Careful monitoring of blood pressure is suggested during concurrent therapy of MAOIs with beta-blockers. Additive hypotensive effects may be seen when phenelzine is combined with antihypertensives. Limited data suggest that bradycardia is worsened when MAOIs are administered to patients receiving beta-blockers. Although the sinus bradycardia observed was not severe, until more data are available, clinicians should use MAOIs cautiously in patients receiving beta-blockers. Patients should be instructed to rise slowly from a sitting position, and to report syncope or changes in blood pressure or heart rate to their health care provider. [27957] [28326] Phenoxybenzamine: (Moderate) Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. [30211] Phentermine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Phentermine; Topiramate: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Phentolamine: (Moderate) Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. [30211] Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Phenytoin: (Minor) Phenytoin is an inducer of hepatic enzymes, and has been shown to accelerate the hepatic metabolism of propranolol. [4998] Pilocarpine: (Moderate) Systemically administered pilocarpine (e.g., when used for the treatment of xerostomia or xerophthalmia) should be administered with caution in patients taking beta-blockers because of the possibility of cardiac conduction disturbances. The risk of conduction disturbances with beta-blockers and ophthalmically administered pilocarpine is low. [9981] Pioglitazone: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Pioglitazone; Glimepiride: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Pioglitazone; Metformin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Piroxicam: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Ponesimod: (Moderate) Monitor for decreases in heart rate if concomitant use of ponesimod and beta-blockers is necessary. Consider a temporary interruption in beta-blocker therapy before initiating ponesimod in patients with a resting heart rate less than or equal to 55 bpm. Beta-blocker treatment can be initiated in patients receiving stable doses of ponesimod. Concomitant use of another beta-blocker with ponesimod resulted in a mean decrease in heart rate of 12.4 bpm after the first dose of ponesimod and 7.4 bpm after beginning maintenance ponesimod. [66527] Pramlintide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Prazosin: (Moderate) Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. [30211] Prednisolone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Prednisone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Prilocaine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. [5731] [5815] Prilocaine; Epinephrine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. [5731] [5815] (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Primidone: (Moderate) Barbiturates can enhance the hepatic metabolism of beta-blockers that are significantly metabolized by the liver, such as propranolol. Clinicians should monitor patients for loss of beta-blockade. [4718] Procainamide: (Major) High or toxic concentrations of procainamide may prolong AV nodal conduction time or induce AV block; these effects could be additive with the pharmacologic actions of beta-blockers, like propranolol. In general, patients receiving combined therapy with procainamide and beta-blockers should be monitored for potential bradycardia, AV block, and/or hypotension. Procainamide's elimination half-life was not significantly changed when administered concomitantly with propranolol. [28250] Promethazine; Phenylephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Propafenone: (Major) Pharmacologically, beta-blockers, like propranolol, cause AV nodal conduction depression and additive effects are possible when used in combination with propafenone. When used together, AV block can occur. Additionally, propafenone, a CYP2D6 inhibitor, appears to inhibit the metabolism of propranolol. Coadministration of propafenone with propranolol increases the plasma concentrations and prolongs the elimination half-life of propranolol; these affects were associated with a 15% decrease in diastolic blood pressure. Patients should be monitored closely and a reduction in the dosage of propranolol may be indicated. [28271] [28287] Propofol: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. [28325] Propylthiouracil, PTU: (Minor) Hyperthyroidism may cause increased clearance of beta blockers that possess a high extraction ratio. A dose reduction of some beta-blockers may be needed when a hyperthyroid patient treated with methimazole becomes euthyroid. [5176] Pseudoephedrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Pseudoephedrine; Triprolidine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Quinidine: (Major) Patients receiving combined therapy with quinidine and propranolol should be monitored for potential hypotension, orthostasis, bradycardia and/or AV block and heart failure, Reduce the beta-blocker dosage if necessary. Quinidine may have additive effects (e.g., reduced heart rate, hypotension) on cardiovascular parameters when used together with beta-blockers, such as propranolol. Quinidine is a known inhibitor of CYP2D6, and may additionally impair the hepatic clearance of propanolol (CYP2D6 substrate); patients should be monitored for excess beta-blockade. [28001] [28249] Quinine: (Minor) Propranolol is significantly metabolized by CYP2D6 isoenzymes. CYP2D6 inhibitors, such as quinine, could theoretically impair propranolol metabolism; the clinical significance of such interactions is unknown. [4718] Racepinephrine: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Ranolazine: (Moderate) Propranolol is metabolized by CYP2D6 isoenzymes. CYP2D6 inhibitors, such as ranolazine, could theoretically impair propranolol metabolism. Lower doses of some CYP2D6 substrates than are usually prescribed may be needed during therapy with ranolazine; monitor therapeutic response during coadministration. [31938] [4718] Rasagiline: (Moderate) Additive hypotensive effects may be seen when monoamine oxidase inhibitors (MAOIs) are combined with antihypertensives. Careful monitoring of blood pressure is suggested during concurrent therapy of MAOIs with beta-blockers. Limited data suggest that bradycardia is worsened when MAOIs are administered to patients receiving beta-blockers. Although the sinus bradycardia observed was not severe, until more data are available, clinicians should use MAOIs cautiously in patients receiving beta-blockers. Patients should be instructed to rise slowly from a sitting position, and to report syncope or changes in blood pressure or heart rate to their health care provider. [4673] [5055] [6398] Regular Insulin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Regular Insulin; Isophane Insulin (NPH): (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Remifentanil: (Moderate) The risk of significant hypotension and/or bradycardia during therapy with remifentanil may be increased in patients receiving beta-blockers or calcium-channel blockers due to additive hypotensive effects. [5630] Repaglinide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Rifabutin: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Rifampin: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Rifamycins: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Rifapentine: (Moderate) Rifamycins are inducers of hepatic enzymes, and may alter the pharmacokinetics of beta-blockers including propranolol. Patients should be monitored for loss of propranolol effects if rifamycins are added. [4998] [5213] [5550] Risperidone: (Moderate) Risperidone may induce orthostatic hypotension and thus enhance the hypotensive effects of propranolol. Lower initial doses or slower dose titration of risperidone may be necessary in patients receiving propranolol concomitantly. [28414] Ritlecitinib: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of ritlecitinib as concurrent use may increase propranolol exposure. Propranolol is a CYP1A2 substrate and ritlecitinib is moderate CYP1A2 inhibitor. [45870] [56853] [69127] Ritonavir: (Moderate) Concurrent administration of propranolol with ritonavir may result in elevated propranolol plasma concentrations. Cardiac and neurologic events have been reported when ritonavir is concurrently administered with beta-blockers. Propranolol is metabolized by the hepatic isoenzyme CYP2D6; ritonavir is an inhibitor of this enzyme. Caution and close monitoring are advised if these drugs are administered together. Decreased beta-blocker dosage may be needed. [28315] [47165] [4998] [58664] Rivastigmine: (Moderate) The increase in vagal tone induced by some cholinesterase inhibitors may produce bradycardia, hypotension, or syncope. The vagotonic effect of these drugs may theoretically be increased when given with other medications known to cause bradycardia such as beta-blockers. [41681] Rizatriptan: (Major) Recommendations for concomitant use of rizatriptan and propranolol vary by dosage form. Concomitant use of rizatriptan oral film and propranolol is contraindicated, and a dosage reduction may be necessary for rizatriptan oral tablets. Limit the rizatriptan dose to 5 mg/dose and 15 mg/24 hours for adults receiving rizatriptan tablets. Avoid use of rizatriptan tablets in pediatric patients weighing less than 40 kg and limit the rizatriptan dose to 5 mg/24 hours in pediatric patients weighing 40 kg or more. Rizatriptan oral film is contraindicated with propranolol because a dose adjustment is not possible. Coadministration has been observed to increase rizatriptan overall exposure by 70% without affecting concentrations of the active N-monodesmethyl metabolite. [31864] [68851] Rocuronium: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Rolapitant: (Major) Use caution if propranolol and rolapitant are used concurrently, and monitor for propranolol-related adverse effects, including bradycardia. Propranolol is a CYP2D6 substrate that is individually dose-titrated, and rolapitant is a moderate CYP2D6 inhibitor; the inhibitory effect of rolapitant is expected to persist beyond 28 days for an unknown duration. Exposure to another CYP2D6 substrate, following a single dose of rolapitant increased about 3-fold on Days 8 and Day 22. The inhibition of CYP2D6 persisted on Day 28 with a 2.3-fold increase in the CYP2D6 substrate concentrations, the last time point measured. [45870] [56853] [60142] Ropivacaine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. [5731] [5815] Rosiglitazone: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Rucaparib: (Moderate) Monitor patients for hypotension and bradycardia if coadministration of propranolol with rucaparib is necessary. Propranolol is a CYP1A2 substrate and rucaparib is a moderate CYP1A2 inhibitor. Concomitant use of CYP1A2 inhibitors may increase exposure to propranolol. [45870] [56853] [61608] Salmeterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Salsalate: (Moderate) Concurrent use of beta-blockers with salsalate and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow. [28982] Saxagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Semaglutide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Serdexmethylphenidate; Dexmethylphenidate: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Sevoflurane: (Major) General anesthetics can potentiate the antihypertensive effects of beta-blockers and can produce prolonged hypotension. Beta-blockers may be continued during general anesthesia as long as the patient is monitored for cardiac depressant and hypotensive effects. [28325] SGLT2 Inhibitors: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Silodosin: (Moderate) During clinical trials with silodosin, the incidence of dizziness and orthostatic hypotension was higher in patients receiving concomitant antihypertensive treatment. Thus, caution is advisable when silodosin is administered with antihypertensive agents. In addition, increased concentrations of silodosin may occur if it is coadministered with carvedilol; exercise caution. Carvedilol is a P-glycoprotein (P-gp) inhibitor and silodosin is a P-gp substrate. [34483] [51834] [58220] Simvastatin: (Minor) After administration of single doses of simvastatin and propranolol, there was a significant decrease in mean Cmax, with no change in AUC, of simvastatin. The clinical significance of this interaction is unknown. Monitor for potential reduced cholesterol-lowering efficacy when propranolol is coadministered with niacin; simvastatin. [10709] Siponimod: (Moderate) Monitor for significant bradycardia with coadministration of siponimod and beta-blockers, as additive lowering effects on heart rate may occur; temporary interruption of beta-blocker treatment may be necessary prior to siponimod initiation. Beta-blocker treatment can be initiated in patients receiving stable doses of siponimod. [64031] Sitagliptin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Sodium Bicarbonate: (Major) Antacids may reduce the absorption of propranolol. The need to stagger doses of propranolol has not been established, but may be prudent. Monitor clinical response, and adjust propranolol dosage if needed to attain therapeutic goals. [4498] Sotagliflozin: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Succinylcholine: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Sufentanil: (Moderate) The incidence and degree of bradycardia and hypotension during induction with sufentanil may be increased in patients receiving beta-blockers. [28001] [30966] Sulfonylureas: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] Sulindac: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Sumatriptan; Naproxen: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Sympathomimetics: (Moderate) Monitor hemodynamic parameters and for loss of efficacy during concomitant sympathomimetic agent and beta-blocker use; dosage adjustments may be necessary. Concomitant use may antagonize the cardiovascular effects of either drug. [24172] [26181] [27369] [28004] [29332] [46537] [46594] [53320] [60070] Tamsulosin: (Minor) Tamsulosin did not potentiate the hypotensive effects of atenolol. However, since the symptoms of orthostasis are reported more frequently in tamsulosin-treated vs. placebo patients, there is a potential risk of enhanced hypotensive effects when co-administered with antihypertensive agents. [29677] Tasimelteon: (Moderate) Advise patients to administer the beta-blocker in the morning if tasimelteon is used concomitantly. Nighttime administration of a beta-blocker may reduce the efficacy of tasimelteon by decreasing the production of melatonin via inhibition of beta1 receptors. [56665] [56699] Telmisartan; Amlodipine: (Moderate) Coadministration of amlodipine and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. [29090] Terazosin: (Moderate) Orthostatic hypotension may be more likely if beta-blockers are coadministered with alpha-blockers. [30211] Terbinafine: (Minor) Propranolol is significantly metabolized by CYP2D6 isoenzymes. CYP2D6 inhibitors, such as terbinafine, could theoretically impair propranolol metabolism. [4718] Terbutaline: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Tetrabenazine: (Moderate) Tetrabenazine may induce orthostatic hypotension and thus enhance the hypotensive effects of antihypertensive agents. Lower initial doses or slower dose titration of tetrabenazine may be necessary in patients receiving antihypertensive agents concomitantly. [34389] Tetracaine: (Moderate) Local anesthetics may cause additive hypotension in combination with antihypertensive agents. Use caution with the concomitant use of tetracaine and antihypertensive agents. [29080] Thalidomide: (Moderate) Thalidomide and other agents that slow cardiac conduction such as beta-blockers should be used cautiously due to the potential for additive bradycardia. [49713] Theophylline, Aminophylline: (Major) Propranolol may significantly decrease aminophylline clearance by inhibiting CYP1A2. In some patients, theophylline levels can increase up to 100%. On average, co-administration of theophylline with propranolol decreases theophylline oral clearance by 30% to 52%. If aminophylline is being initiated in a patient who is already taking a drug that inhibits its clearance, the dose required to achieve a therapeutic serum theophylline concentration will be smaller. Patients should be closely monitored for toxicity. Serum theophylline concentrations should be monitored. Because propranolol is non-selective, the beta-2 blocking activity may reduce the effectiveness of aminophylline and other treatments for asthma or COPD. Discontinuation of a concomitant drug that inhibits aminophylline clearance will result in decreased serum theophylline concentrations, unless the aminophylline dose is appropriately increased. [44294] [53617] (Major) Propranolol may significantly decrease theophylline clearance by inhibiting CYP1A2. In some patients, theophylline levels can increase up to 100%. On average, co-administration of theophylline with propranolol decreases theophylline oral clearance by 30% to 52%. If theophylline is being initiated in a patient who is already taking a drug that inhibits its clearance, the dose of theophylline required to achieve a therapeutic theophylline concentration will be smaller. Patients should be closely monitored for toxicity. Serum theophylline concentrations should be monitored. Because propranolol is non-selective, the beta-2 blocking activity may reduce the effectiveness of theophylline and other treatments for asthma or COPD. Discontinuation of a concomitant drug that inhibits theophylline clearance will result in decreased theophylline concentrations, unless the theophylline dose is appropriately increased. [44294] [53617] Thiazolidinediones: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Thioridazine: (Contraindicated) Coadministration of thioridazine and propranolol is contraindicated due to the potential for increased thioridazine exposure. Increased plasma concentrations of thioridazine are expected to increase the prolongation of the QTc interval associated with thioridazine and may increase the risk of serious, potentially fatal, cardiac arrhythmias, such as torsade de pointes type arrhythmias. Propranolol has been observed to increase thioridazine exposure by 370%. [28293] [56853] Thiothixene: (Moderate) Thiothixene should be used cautiously in patients receiving antihypertensive agents. Additive hypotensive effects are possible. [46957] Thyroid hormones: (Minor) Because thyroid hormones cause cardiac stimulation including increased heart rate and increased contractility, the effects of beta-blockers may be reduced by thyroid hormones. The reduction of effects may be especially evident when a patient goes from a hypothyroid to a euthyroid state or when excessive amounts of thyroid hormone is given to the patient. [29527] [43942] Tiotropium; Olodaterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Tirzepatide: (Moderate) Increased frequency of blood glucose monitoring may be required when a beta blocker is given with antidiabetic agents. Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes. Other symptoms, like headache, dizziness, nervousness, mood changes, or hunger are not blunted. Beta-blockers also exert complex actions on the body's ability to regulate blood glucose. Some beta-blockers, particularly non-selective beta-blockers such as propranolol, have been noted to potentiate insulin-induced hypoglycemia and a delay in recovery of blood glucose to normal levels. Hyperglycemia has been reported as well and is possibly due to beta-2 receptor blockade in the beta cells of the pancreas. A selective beta-blocker may be preferred in patients with diabetes mellitus, if appropriate for the patient's condition. Selective beta-blockers, such as atenolol or metoprolol, do not appear to potentiate insulin-induced hypoglycemia. While beta-blockers may have negative effects on glycemic control, they reduce the risk of cardiovascular disease and stroke in patients with diabetes and their use should not be avoided in patients with compelling indications for beta-blocker therapy when no other contraindications are present. [28618] [29403] [30489] [30575] [32916] [53617] [62853] Tizanidine: (Moderate) Concurrent use of tizanidine with antihypertensive agents can result in significant hypotension. Caution is advised when tizanidine is to be used in patients receiving concurrent antihypertensive therapy. [52430] Tobacco: (Major) Advise patients to avoid smoking tobacco while taking propranolol. Smoking tobacco has been observed to decrease propranolol exposure by approximately 50% and may decrease efficacy. [28327] [67633] Tolmetin: (Moderate) Monitor blood pressure during concomitant beta-blocker and nonsteroidal anti-inflammatory drug (NSAID) use. The antihypertensive effect of beta-blockers may be diminished by NSAIDs. [32122] Trandolapril; Verapamil: (Major) Intravenous propranolol is contraindicated with intravenous verapamil use in close proximity (within a few hours). Fatal cardiac arrests have occurred in patients receiving intravenous beta-blockers and intravenous calcium channel blockers. Use oral propranolol and oral verapamil with caution and close monitoring due to risk for additive negative effects on heart rate, AV conduction, and/or cardiac contractility. There have been reports of excess bradycardia and AV block, including complete heart block, when beta-blockers and verapamil have been used for the treatment of hypertension. A decrease in propranolol clearance has been observed when administered concomitantly with verapamil. [33374] [45870] [56103] Tranylcypromine: (Major) Avoid concomitant use of beta-blockers and tranylcypromine due to the risk of additive hypotension and/or severe bradycardia. Potential for this interaction persists for up to 10 days after discontinuation of tranylcypromine (or 4 to 5 half-lives after discontinuation of the beta-blocker). If a medication-free interval is not feasible, initiate therapy at the lowest appropriate dose and monitor blood pressure and heart rate closely. [28537] [29656] Trazodone: (Minor) Due to additive hypotensive effects, patients receiving antihypertensive agents concurrently with trazodone may have excessive hypotension. Decreased dosage of the antihypertensive agent may be required when given with trazodone. [28719] Triamcinolone: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Trifluoperazine: (Moderate) Monitor for an increase in trifluoperazine and propranolol-related adverse effects during concomitant use. The concentrations of both medications may increase. [43071] Umeclidinium; Vilanterol: (Moderate) Beta-blockers will block the pulmonary effects of inhaled beta-agonists, and in some cases may exacerbate bronchospasm in patients with reactive airways. Beta-agonists can sometimes increase heart rate or have other cardiovascular effects, particularly when used in high doses or if hypokalemia is present. Use of a beta-1-selective (cardioselective) beta blocker is recommended whenever possible when this combination of drugs must be used together. Monitor the patient's lung and cardiovascular status closely. Beta-agonists and beta-blockers are pharmacologic opposites and will counteract each other to some extent when given concomitantly, especially when non-cardioselective beta blockers are used. [28618] [43675] [44979] [51834] [58220] Vecuronium: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. [42039] [65345] Vemurafenib: (Moderate) Propranolol is significantly metabolized by CYP2D6 and secondarily by the CYP1A2 isoenzymes. CYP2D6 and CYP1A2 inhibitors, such as vemurafenib, could theoretically impair propranolol metabolism. The clinical significance of such interactions is unknown. [45335] [4998] Verapamil: (Major) Intravenous propranolol is contraindicated with intravenous verapamil use in close proximity (within a few hours). Fatal cardiac arrests have occurred in patients receiving intravenous beta-blockers and intravenous calcium channel blockers. Use oral propranolol and oral verapamil with caution and close monitoring due to risk for additive negative effects on heart rate, AV conduction, and/or cardiac contractility. There have been reports of excess bradycardia and AV block, including complete heart block, when beta-blockers and verapamil have been used for the treatment of hypertension. A decrease in propranolol clearance has been observed when administered concomitantly with verapamil. [33374] [45870] [56103] Viloxazine: (Moderate) Monitor for increased propranolol adverse reactions, including bradycardia and hypotension, during coadministration of viloxazine as concurrent use may increase propranolol exposure. Propranolol is a CYP2D6 and CYP1A2 substrate and viloxazine is a strong 1A2 inhibitor and a weak CYP2D6 inhibitor. [45870] [53617] [56853] [66575] Voriconazole: (Moderate) Voriconazole is metabolized by CYP3A4 and, theoretically, inhibitors of CYP3A4, such as propranolol, could lead to increased serum levels of voriconazole. [4718] Warfarin: (Moderate) Propranolol has been shown to increase warfarin AUC, and concurrent increases in INR values have been reported. Patients should be monitored for changes in anticoagulation parameters during concurrent therapy with propranolol and warfarin. [23809] Zileuton: (Moderate) Concomitant administration of zileuton and propranolol results in a significant increase in propranolol serum concentrations, AUC, and elimination half-life. Bradycardia is also potentiated by the drug combination. Clinicians should monitor vital signs carefully if zileuton is added to a regimen containing propranolol and adjust dosages as needed. [28684] Ziprasidone: (Minor) Ziprasidone is a moderate antagonist of alpha-1 receptors and may cause orthostatic hypotension with or without tachycardia, dizziness, or syncope. Additive hypotensive effects are possible if ziprasidone is used concurrently with antihypertensive agents. [28233] Zolmitriptan: (Minor) Periodically monitor blood pressure and for zolmitriptan-related side effects in patients who regularly use zolmitriptan and are taking propranolol. Rarely, a patient might experience an increase in dose-related common side effects of zolmitriptan, such as dizziness, nausea or drowsiness. No dosage adjustment of zolmitriptan appears to be needed. During pharmacokinetic studies, the Cmax and AUC of zolmitriptan increased 1.5-fold after 1 week of dosing with propranolol. Cmax and AUC of the active N-desmethyl metabolite of zolmitriptan were reduced by 30% and 15%, respectively. However, in clinical trials, the efficacy of zolmitriptan was not affected by the concurrent use of common migraine prophylactic drugs (e.g., propranolol). There were no interactive effects on blood pressure or pulse rate. The interaction should not be significant for most patients. [28445]
Revision Date: 02/02/2024, 02:07:00 AM

References

235 - Gay GR, Loper KA. Control of cocaine-induced hypertension with labetalol. Anesth Analg 1988;67:92.805 - The sixth report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. National Institute of Health publication No 99-4080. 1997;1-64.4498 - Murphey LM, Hood EH. Bosentan and warfarin interaction. Ann Pharmacother 2003;37:1028-31.4673 - Nardil (phenelzine) tablet package insert. New York, NY: Pfizer; 2009 Feb.4718 - Hansten PD, Horn JR. Cytochrome P450 Enzymes and Drug Interactions, Table of Cytochrome P450 Substrates, Inhibitors, Inducers and P-glycoprotein, with Footnotes. In: The Top 100 Drug Interactions - A guide to Patient Management. 2008 Edition. Freeland, WA: H&H Publications; 2008:142-157.4794 - Colestid (colestipol hydrochloride tablets) package insert. New York, NY: Pharmacia & Upjohn Company; 2017 Jul.4989 - Clozaril (clozapine) tablets package insert. Rosemont, PA: HLS Therapeutics (USA), Inc.; 2023 May.4998 - Propranolol tablet package insert. Parsippany, NJ: Actavis Pharma, Inc.; 2015 Aug.5001 - Trujillo TC, Nolan PE. Antiarrhythmic agents: drug interactions of clinical significance. Drug Saf 2000;23:509-32.5028 - Halawa B. Interactions of quinidine and propranolol with mexiletine, encainide, flecainide, and tocainamide Pol Tyg Lek 1990;45:222-4. Abstract.5029 - Rubino M, Jackson E. Severe paranoia with concomitant tocainide and propranolol therapy. Clin Pharm 1982;1:177-9.5053 - Ramoska E, Sacchetti AD. Propranolol-induced hypertension in treatment of cocaine-intoxication. Ann Emerg Med 1985;14:1112-3.5054 - Quist Christiansen L, Bonde J, Kampmann JP. Drug interactions with inhalational anesthetics. Acta Anaesthesiol Scand 1993;37:231-44.5055 - Reggev A, Vollhardt BR. Bradycardia induced by an interaction between phenelzine and beta blockers. Psychosomatics 1989;30:106-8.5057 - Hibbard DM, Peters JR, Hunninghake DB. Effects of cholestyramine and colestipol on the plasma concentrations of propranolol. Br J Clin Pharmacol 1984;18:337-42.5176 - Tapazole® (methimazole) package insert. Indianapolis, IN: Eli Lilly and Company; 1999 July.5206 - Rescriptor (delavirdine) package insert. Research Triangle Park, NC: ViiV Healthcare; 2019 Aug.5213 - Priftin (rifapentine) package insert. Bridgewater, NJ: Sanofi-Aventis Pharmaceuticals Inc.; 2020 Jun.5265 - Cerebyx (fosphenytoin sodium) package insert. New York, NY: Pfizer Labs; 2022 Apr.5269 - Toprol-XL (metoprolol succinate) tablet package insert. Lincolnshire, IL: Melinta Therapeutics; 2023 Mar.5330 - Zyvox (linezolid) package insert. New York, NY: Pharmacia and Upjohn Company; 2023 July.5414 - Nefazodone tablet package insert. North Wales, PA: Teva Pharmaceuticals USA, Inc.; 2015 Sept.5517 - Zyprexa (olanzapine, all formulations) package insert. Indianapolis, IN: Eli Lilly and Company; 2020 Apr.5550 - Rifampin Injection package insert. Bedford, OH: Bedford Laboratories; 2000 Nov.5558 - Betapace AF (sotalol hydrochloride) package insert. Montville, NJ: Berlex Laboratories; 2003 Apr.5630 - Ultiva (remifentanil) package insert. Morgantown, WV: Mylan Institutional LLC; 2023 Dec.5731 - Septocaine (articaine; epinephrine injection) package insert. Louisville, CO: Septodont, Inc.; 2018 Nov.5815 - Naguib M, Magboul MMA, Samarkandi AH, et al. Adverse effects and drug interactions associated with local and regional anesthesia. Drug Safety 1998;18:221-50.5942 - Gonzalez JP, Valdivieso A, Calvo R, et al. Influence of vitamin C on the absorption and first pass metabolism of propranolol. Eur J Clin Pharmcol 1995;48:295-7.5943 - Brosen K. Drug interactions and the cytochrome P450 system. The role of cytochrome P4501A2. Clin Pharmacokinet 1995;29: Suppl 1:20-5.6133 - Holmes B, Brogden RN, Heel RC, et al. Guanabenz. A review of its pharmacodynamic properties and therapeutic efficacy in hypertension. Drugs 1983;26:212-29.6289 - Hoffman BB, Lefkowitz RJ. Catecholamines and sympathomimetic drugs. Gilman AG, Rall TW, Nies AS, Taylor P, (eds.) In: Goodman and Gilman's Pharmacological Basis of Therapeutics. 8th ed., New York, Pergamon Press. 1990. 187-91.6316 - Trental (pentoxifylline) package insert. Bridgewater, NJ: Sanofi-Aventis Pharmaceuticals Inc.; 2010 Jun.6398 - Parnate (tranylcypromine) package insert. St. Michael, Barbados: Concordia Pharmaceuticals; 2018 Jan.6532 - Nembutal (pentobarbital sodium) injection. Lake Forest, IL: Oak Pharmaceuticals, Inc.; 2018 Dec.7463 - Gill J, Singh H, Nugent K. Acute lithium intoxication and neuroleptic malignant syndrome. Pharmacotherapy 2003;23:811-15.7629 - Milrinone injection package insert. Deerfield, IL: Baxter Healthcare Corporation; 2018 May.9981 - Pilocarpine Hydrochloride tablets package insert. Melville, NY: Amici Pharmaceuticals, LLC; 2018 Oct.10709 - Simcor (niacin-simvastatin) prescribing information. Abbott Park, IL: Abbott; 2013 Feb.23809 - Wells PS, Holbrook AM, Crowther NR, et al. Interaction of warfarin with drugs and food. Ann Intern Med 1994;121:676-83.24172 - Coates ML, et al. Does pseudoephedrine increase blood pressure in patients with controlled hypertension? J Fam Pract 1995;40:22-6.25572 - Kobayashi M, Shoji N, Ohizumi Y. Gingerol, a novel cardiotonic agent, activates the Ca2+-pumping ATPase in skeletal and cardiac sarcoplasmic reticulum. Biochim Biophys Acta 1987;903:96-102.26181 - Chua SS, Benrimoj SI. Non-prescription sympathomimetic agents and hypertension. Med Toxicol Adverse Drug Exp 1988;3:387-417.26512 - Palomeras E, Sanz P, Cano A, et al. Dystonia in a patient treated with propranolol and gabapentin. Arch Neurol 2000;57:570-571.27369 - Beck RA, Mercado DL, Seguin SM, et al. Cardiovascular effects of pseudoephedrine in medically controlled hypertensive patients. Arch Intern Med 1992;152:1242-5.27653 - Alexander HE Jr, McCarty K, Giffen MB. Hypotension and cardiopulmonary arrest associated with concurrent haloperidol and propranolol therapy. JAMA 1984;252:87-8.27942 - Campath (alemtuzumab) injection package insert. Cambridge, MA: Genzyme Corporation; 2023 Apr.27957 - Nardil (phenelzine) tablet package insert. New York, NY: Pfizer; 2009 Feb.27964 - Dostinex (cabergoline) package insert. Kalamazoo, MI: Pharmacia and Upjohn Company; 2019 Dec.28001 - Hansten PD, Horn JR. Cytochrome P450 Enzymes and Drug Interactions, Table of Cytochrome P450 Substrates, Inhibitors, Inducers and P-glycoprotein, with Footnotes. In: The Top 100 Drug Interactions - A guide to Patient Management. 2008 Edition. Freeland, WA: H&H Publications; 2008:142-157.28004 - Isuprel (isoproterenol) package insert. Bridgewater, NJ: Bausch Health US, LLC; 2022 Oct.28126 - Sensipar (cinacalcet) package insert. Thousand Oaks, CA: Amgen Inc.; 2019 Dec.28142 - Reyataz (atazanavir) package insert. Princeton, NJ: Bristol-Myers Squibb Company; 2023 Nov.28224 - Pacerone (amiodarone) tablets package insert. Maple Grove, MN: Upsher-Smith Laboratories, LLC.; 2018 Nov.28228 - Norpace and Norpace CR (disopyramide) package insert. Chicago, IL: G.D. Searle LLC division of Pfizer Inc; 2016 Aug.28233 - Geodon (ziprasidone) package insert. New York, NY: Pfizer: 2021 May.28249 - Quinidine sulfate extended release tablets package insert. Sellersville, PA: Teva Pharmaceuticals USA; 2003 Jun.28250 - Procanbid (procainamide) package insert. Bristol, TN: Monarch Pharmaceuticals; 2002 Jan.28261 - Uroxatral (alfuzosin extended-release tablets) package insert. St. Michael, Barbados: Concordia Pharmaceuticals, INC.; 2015 May.28269 - Celexa (citalopram) tablets package insert. Madison, NJ: Allergan USA, Inc.; 2023 Aug.28271 - Propranolol tablet package insert. Parsippany, NJ: Actavis Pharma, Inc.; 2015 Aug.28272 - Lanoxin (digoxin) tablets package insert. St. Michael, Barbados: Concordia Pharmaceuticals Inc.; 2020 Apr..28287 - Rythmol SR (propafenone hydrochloride) capsule extended release package insert. Research Triangle Park, NC: GlaxoSmithKline; 2018 Nov.28289 - Tambocor (flecainide) package insert. Northridge, CA: 3M Pharmaceuticals; 1998 Jul.28290 - Catapres tablets (clonidine) package insert. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2016 Aug.28293 - Thioridazine package insert. Morgantown, WV: Mylan Pharmaceuticals Inc.; 2016 Nov.28295 - Leor J, Levartowsky D, Sharon C, et al. Amiodarone and beta-adrenergic blockers: an interaction with metoprolol but not with atenolol. Am Heart J 1988;116:206-7.28296 - Boutite F, Boissel JP, Connolly SJ, et al. Amiodarone interaction with beta-blockers: analysis of the merged EMIAT (European myocardial infarct amiodarone trial) and CAMIAT (Canadian amiodarone infarction trial) databases. Circulation 1999;99:2268-75.28301 - Mefloquine hydrochloride package insert. North Wales PA: Teva Pharmaceuticals USA Inc.; 2019 Mar.28307 - Haldol (haloperidol) injection for immediate release package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2020 Feb.28315 - Norvir (ritonavir capsules) package insert. North Chicago, IL: AbbVie Inc; 2020 Oct.28325 - Quist Christiansen L, Bonde J, Kampmann JP. Drug interactions with inhalational anesthetics. Acta Anaesthesiol Scand 1993;37:231-44.28326 - Reggev A, Vollhardt BR. Bradycardia induced by an interaction between phenelzine and beta blockers. Psychosomatics 1989;30:106-8.28327 - Zevin S, Benowitz NL. Drug interactions with tobacco smoking: an update. Clin Pharmacokinet 1999;36:425-38.28414 - Risperdal (risperidone tablets, oral solution, and orally disintegrating tablets) package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2022 Aug.28445 - Zomig (zolmitriptan) tablets package insert. Hayward, CA: Impax Specialty Pharma; 2018 Dec.28537 - Coreg (carvedilol) package insert. Wixom, MI: Woodward Pharma Services LLC; 2023 Jul.28539 - Toprol-XL (metoprolol succinate) tablet package insert. Lincolnshire, IL: Melinta Therapeutics; 2023 Mar.28618 - Tenormin (atenolol) package insert. Morristown, NJ: Almatica Pharma LLC.; 2023 Dec.28627 - GlucaGen (glucagon) package insert. Ridgefield, CT: Boehringer Ingleheim Pharmaceuticals, Inc.; 2021 Jul.28661 - Apokyn and Apokyn Pen (apomorphine) injection package insert. Rockville, MD: MMD US Operations, LLC; 2022 Jun28684 - Zyflo Filmtab (zileuton) package insert. Chicago, IL: Abbott Laboratories; 1998 Mar.28719 - Desyrel® (trazodone) package insert. Princeton, NJ: Bristol-Myers Squibb; 2005 Jan.28852 - Cafergot (caffeine; ergotamine) tablets package insert. Princeton, NJ: Sandoz, Inc.; 2018 May.28896 - Yamreudeewong W, DeBisschop M, Martin LG, et al. Potentially significant drug interactions of class III antiarrhythmic drugs. Drug Saf 2003;26:421-38.28947 - Corlopam (fenoldopam mesylate) package insert. Lake Forest, IL: Hospira, Inc., 2020 Sept.28963 - Omnipaque (iohexol) package insert. Marlborough, MA: GE Healthcare, Inc.; 2023 Feb.28982 - U.S. Department of Health and Human Services (DHHS), FDA, 21 CFR Part 343 (Docket No. 77N-094A). Internal analgesic, antipyretic, and antirheumatic drug products for over-the-counter human use; final rule for professional labeling of aspirin, buffered aspirin, and aspirin in combination with antacid drug products. Retrieved May 6, 2004. Published October 23, 1998 on the World Wide Web at: http://www.fda.gov.28997 - Thorazine (chlorpromazine) package insert. Research Triangle Park, NC: GlaxoSmithKline; 2017 Mar.29061 - Natrecor (nesiritide) package insert. Fremont, CA: Scios Inc..; 2008 Dec.29068 - Procardia (nifedipine) package insert. New York, NY: Pfizer Labs, Inc.; 2016 Jul.29080 - Naguib M, Magboul MMA, Samarkandi AH, et al. Adverse effects and drug interactions associated with local and regional anesthesia. Drug Safety 1998;18:221-50.29082 - Nimodipine capsule package insert. Livonia, MI: Major Pharmaceuticals; 2015 Dec.29088 - Sular (nisoldipine) package insert. Atlanta, GA: Shionogi Pharma, Inc.; 2017 Jun.29090 - Norvasc (amlodipine) package insert. New York, NY: Pfizer Labs; 2019 Jan.29112 - Precedex (dexmedetomidine) injection package insert. Lake Forest, IL: Hospira; 2022 Dec.29113 - Sandostatin (octreotide) package insert. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2024 Jan.29121 - Relpax (eletriptan hydrobromide) package insert. New York, NY: Pfizer Inc.; 2020 Mar.29128 - DynaCirc CR (isradipine) package insert. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2009 Feb.29332 - Adderall XR (amphetamine; dextroamphetamine) package insert. Lexington, MA: Takeda Pharmaceuticals America, Inc.; 2023 Oct.29386 - Nitro-Dur (nitroglycerin) package insert. Kenilworth, NJ; Key Pharmaceuticals, Inc.; 2003 August.29403 - Gilbert RE, Cooper ME, Krum H. Drug Administration in Patients with Diabetes Mellitus, Safety Considerations. Drug Safety 1998;18:441-55.29484 - Iopidine (apraclonidine 1%) package insert. Fort Worth, TX: Alcon Laboratories, Inc.; 2018 Mar.29527 - Cytomel (liothyronine) package insert. St. Louis, MO: Jones Pharma Incorporated; 2001 Nov.29529 - White JR, Campbell RK. Dangerous and common drug interactions in patients with diabetes mellitus. Endocrinol Metab Clin North Am 2000;29:789-802.29537 - Hyperstat (diazoxide) injection package insert. Kenilworth, NJ: Schering Corporation; 2006 May.29571 - Nitropress (nitroprusside) package insert. North Chicago, IL: Abbott Laboratories; 1990 Oct.29627 - PegIntron (peginterferon alfa-2b) package insert. Whitehouse Station, NJ: Merck and Co., Inc.; 2019 Jan.29656 - Parnate (tranylcypromine) package insert. St. Michael, Barbados: Concordia Pharmaceuticals; 2018 Jan.29677 - Flomax (tamsulosin) package insert. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2014 Oct.29934 - Cymbalta (duloxetine hydrochloride) delayed-release capsules package insert. Indianapolis, IN: Eli Lilly and Company; 2023 Aug.30211 - Hytrin (terazosin) package insert. North Chicago, IL: Abbott Laboratories; 2009 Jul.30489 - Chobanian AV, Bakris GL, Black HR. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 2003;289:2560-71.30536 - Howe PR. Dietary fats and hypertension. Focus on fish oil. Ann N Y Acad Sci 1997;827:339-52.30537 - Woodman RJ, Mori TA, Burke V, et al. Effects of purified eicosapentaenoic and docosahexaenoic acids on glycemic control, blood pressure, and serum lipids in type 2 diabetic patients with treated hypertension. Am J Clin Nutr 2002;76:1007-15.30538 - Morris MC, Sacks F, Rosner B. Does fish oil lower blood pressure? A meta-analysis of controlled trials. Circulation 1993;88:523-33.30539 - Appel LJ, Miller ER, Seidler AJ, et al. Does supplementation of diet with 'fish oil' reduce blood pressure? A meta-analysis of controlled clinical trials. Arch Intern Med 1993;153:1429-38.30540 - Geleijnse JM, Giltay EJ, Grobbee DE, et al. Blood pressure response to fish oil supplementation: metaregression analysis of randomized trials. J Hypertens 2002;20:1493-9.30575 - Luna B, Feinglos MN. Drug-induced hyperglycemia. JAMA 2001;286:1945-8.30582 - Baclofen package insert. Philadelphia, PA: Lannett Company, Inc.; 2007 Dec.30711 - Enablex (darifenacin extended-release tablets) package insert. Madison, NJ: Allergan USA, Inc.; 2021 Jul.30774 - Ventavis (iloprost) package insert. Titusville, NJ: Actelion Pharmaceuticals US, Inc.; 2022 Mar.30847 - MUSE (alprostadil) urethral suppository package insert. Somerset, NJ: Meda Pharmaceuticals; 2018 Apr.30849 - Caverject (alprostadil for injection) package insert. New York, NY: Pharmacia and Upjohn Company; 2022 Dec.30948 - Bentue-Ferrer D, Tribut O, Polard E, Allain H. Clinically significant drug interactions with cholinesterase inhibitors: a guide for neurologists. CNS Drugs 2003;17:947-63.30966 - Sufentanil citrate injection package insert. Lake Forest, IL: Akorn Pharmaceuticals, Inc.; 2023 Dec31749 - Adalat CC (nifedipine extended-release tablets) package insert. Cookeville, TN: Aphena Pharma Solutions; 2014 May.31864 - Maxalt and Maxalt-MLT (rizatriptan) package insert. Jersey City, NJ: Organon LLC; 2021 Jun.31938 - Ranexa (ranolazine extended-release tablets) package insert. Foster City, CA: Gilead Sciences, Inc. 2019 Oct.32061 - Brosen K. Some aspects of genetic polymorphism in the biotransformation of antidepressants. Therapie 2004;59:5-12.32062 - Hemeryck A, Belpaire FM. Selective serotonin reuptake inhibitors and cytochrome P-450 mediated drug-drug interactions: an update. Curr Drug Metab 2002;3:13-37.32122 - EC Naprosyn (naproxen delayed-release tablets), Naprosyn (naproxen tablets), Anaprox DS (naproxen sodium tablets) package insert. Alpharetta, GA: Canton Laboratories, LLC; 2021 Apr.32841 - AK-Fluor (fluorescein injection) package insert. Lake Forest, IL: Akorn; 2019 Aug.32843 - Joint Council of Allergy, Asthma, and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol 2005;115:S483-523.32916 - Lopressor (metoprolol tartrate) tablets and injection. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2012 Dec.32936 - Invega (paliperidone) extended-release tablets package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2022 Mar.33374 - Calan (verapamil hydrochloride injection) package insert. New York, NY: Pfizer Inc; 2011 Oct.33467 - Nuvigil (armodafinil) package insert. Frazer, PA: Cephalon Inc; 2017 Feb.33519 - Somatuline Depot (lanreotide) package insert. Signes, France: Ipsen Pharma Biotech; 2023 Feb.34389 - Xenazine (tetrabenazine) package insert. Deerfield, IL: Lundbeck, Inc.; 2017 Sep.34483 - Rapaflo (silodosin) package insert. Madison, NJ: Allergan USA, Inc.; 2020 Dec.34626 - Vimpat (lacosamide) package insert. Smyrna, GA: UCB, Inc.; 2023 Oct.34900 - Rosenfeldt F, Hilton D, Pepe S, et al. Systematic review of effect of coenzyme Q10 in physical exercise, hypertension and heart failure. Biofactors 2003;18:91-100.34940 - Pristiq (desvenlafaxine) extended-release tablets package insert. Philadelphia, PA: Wyeth Pharmaceuticals Inc.; 2023 Aug.35401 - Coartem (artemether; lumefantrine) package insert. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2019 Aug.36101 - Multaq (dronedarone) package insert. Bridgewater, NJ: Sanofi-Aventis U.S. LLC; 2023 Oct.36146 - Fanapt (iloperidone) package insert. Rockville, MD: Vanda Pharmaceuticals, Inc.; 2017 Mar.36343 - Saphris (asenapine) sublingual tablet package insert. St. Louis, MO: Forest Pharmaceuticals, Inc.; 2017 Mar.40143 - Innopran XL (propranolol hydrochloride) package insert. Baudette, MN: ANI Pharmaceuticals, Inc.; 2023 Dec.40936 - Invega Sustenna (paliperidone palmitate injectable suspension) package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2022 Jul.41057 - Wellbutrin XL (bupropion) package insert. Bridgewater, NJ: Bausch Health US, LLC; 2022 Mar.41243 - Provigil (modafinil) package insert. Frazer, PA: Cephalon; 2015 Jan.41681 - Exelon (rivastigmine) capsule and oral solution package insert. East Hanover, NJ: Novartis Pharmaceutical Corporation; 2016 Nov.41823 - Gilenya (fingolimod) package insert. East Hanover, New Jersey: Novartis Pharmaceuticals Corporation; 2023 Aug.41853 - Proleukin (aldesleukin) package insert. Malvern, PA: Clinigen, Inc.; 2023 Sept.42039 - Quelicin (succinylcholine) injection package insert. Lake Forest, IL: Hospira, Inc.; 2022 Nov.42063 - Catapres TTS (clonidine) extended-release patch package insert. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2016 Aug.42227 - Latuda (lurasidone) package insert. Marlborough, MA: Sunovion Pharmaceuticals, Inc.; 2019 Dec.42845 - Abilify (aripiprazole) tablets, discmelt orally-disintegrating tablets, oral solution, and intramuscular injection package insert. Rockville, MD: Otsuka America Pharmaceutical, Inc.; 2022 Nov.43071 - Trifluoperazine package insert. Princeton, NJ:Sandoz Inc; 2017 Mar.43606 - Adenoscan (adenosine injection) package insert. Lake Forest, Il: Hospira, Inc; 2014 Aug.43663 - Dutoprol (hydrochlorothiazide; metoprolol succinate) extended-release tablets. St. Michael, Barbados: Concordia Pharmaceuticals Inc.; 2022 Jan.43675 - Ipratropium bromide; Albuterol sulfate Inhalation Solution for Nebulizer package insert. Warren, NJ: Cipla USA, Inc.; 2020 Feb.43792 - Provocholine (methacholine chloride) powder for inhalation package insert. Brantford, Ontario, Canada: Methapharm Inc.; 2020 Nov.43887 - Sylatron (peginterferon alfa-2b) package insert. Whitehouse Station, NJ: Merck & Co, Inc; 2018 Dec.43942 - Levothroid (levothyroxine sodium tablet) package insert. Shenandoah, IA: Lloyd Pharmaceutical; 2011 June.44027 - Niacor (Niacin tablets) package insert. Minneapolis, MN: Upsher-Smith Laboratories, Inc.; 2000 Feb.44058 - Prozac Weekly (fluoxetine hydrochloride delayed-release capsules) package insert. Indianapolis, IN: Lilly USA, LLC; 2017 Mar.44156 - Zytiga (abiraterone acetate) tablets package insert. Horsham, PA: Janssen Biotech, Inc.; 2021 Aug.44294 - Theo-24 (theophylline, anhydrous) package insert. Malvern, PA: Endo Pharmaceuticals, Inc.; 2019 Mar.44979 - Arcapta Neohaler (indacaterol inhalation powder) package insert. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2021 July.45135 - Rectiv (nitroglycerin ointment 0.4%) package insert. Bedminster, NJ: ProStrakan, Inc.; 2011 Jun.45335 - Zelboraf (vemurafenib) tablet package insert. South San Francisco, CA: Genentech USA, Inc.; 2020 May.45458 - Xalkori (crizotinib) capsules and pellets package insert. New York, NY: Pfizer Labs; 2023 Sept.45688 - Diltiazem hydrochloride injection package insert. Lake Forest, IL: Hospira, Inc.; 2017 Dec.45870 - Propranolol HCl injection package insert. Berkeley Heights, NJ: Hikma Pharmaceuticals USA Inc; 2022 May.46370 - Onfi (clobazam) package insert. Deerfield, IL: Lundbeck Inc.; 2023 Jan.46537 - Adipex-P (phentermine hydrochloride tablets and capsules) package insert. Parsippany, NJ: Teva Pharmaceuticals USA, Inc.; 2020 Sept.46594 - Suprenza (phentermine hydrochloride) package insert. Cranford, NJ: Akrimax Pharmaceuticals; 2011 Oct.46957 - Navane (thiothixene capsules) package insert. New York, NY: Pfizer, Inc.; 2017 Mar.47165 - Norvir (ritonavir tablets, solution, and powder) package insert. North Chicago, IL: AbbVie Inc; 2022 Dec.48617 - Evoxac (cevimeline) package insert. Edison, NJ: Daiichi Sankyo Pharma Development; 2018 April.48681 - Sinemet (carbidop-levodopa) tablets package insert. Whitehouse Station, NJ: Merck & Co., Inc.; 2018 Apr.48893 - Methergine (methylergonovine maleate) tablets package insert. East Hanover, NJ: Lupin Pharmaceuticals Inc.; 2016 Jan.49124 - Ethyol (amifostine) package insert. Nashville, TN: Cumberland Pharmaceuticals, Inc.; 2019 Jul.49612 - Visipaque (iodixanol) package insert. Marlborough, MA: GE Healthcare, Inc.; 2023 Feb.49632 - Connolly SJ, Dorian P, Roberts RS, et al. Comparison of beta-blockers, amiodarone plus beta-blockers, or sotalol for prevention of shocks from implantable cardioverter defibrillators: the OPTIC Study: a randomized trial. JAMA. 2006;295:165-7149708 - Melikian V, Eddy JD, Paton A. The stimulant effect of drugs on indocyanine green clearance by the liver. Gut 1972;13:755-758.49709 - Bauer LA, Murray K, Horn JR, et al. Influence of nifedipine therapy on indocyanine green and oral propranolol pharmacokinetics. Eur J Clin Pharmacol 1989;37:257-260.49713 - Thalomid (thalidomide) package insert. Summit, NJ: Celgene Corporation; 2013 Feb.49823 - Afinitor (everolimus) tablets package insert. East Hanover, NJ:Novartis Pharmaceuticals Corporation; 2022 Feb.49903 - Zortress (everolimus) package insert. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2023 Sept.49952 - Fibricor (fenofibric acid) package insert. Athens, GA: Athena Bioscience LLC.; 2021 Jun.50324 - Cimetidine package insert. Oklahoma City, OK: PD-Rx Pharmaceuticals, Inc.; 2022 Aug.51111 - Myrbetriq (mirabegron extended-release tablets and oral suspension) package insert. Northbrook, Illinois: Astellas Pharma US, Inc.; 2021 March.51310 - Sandostatin LAR Depot (octreotide acetate) injection package insert. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2024 Jan.51323 - Vascepa (icosapent ethyl) package insert. Bridgewater, NJ: Amarin Pharma Inc.; 2019 Dec.51834 - Food and Drug Administration (FDA): Drug development and drug interactions. Retrieved Sep 19, 2012. Available on the World Wide Web http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.htm#transporter.52430 - Tizanidine (Zanaflex) tablets and capsules package insert. 6300 Switzerland: Covis Pharma Zug; 2020 Dec.52611 - Signifor (pasireotide diaspartate) package insert. Stein, Switzerland: Novartis Pharma Stein AG; 2020 Jan.53320 - Markowitz JS, Patrick KS. Pharmacokinetic and pharmacodynamic drug interactions in the treatment of attention-deficit hyperactivity disorder. Clin Pharmacokinet 2001;40:753-72.53347 - DeVane CL, Donovan JL, Liston HL, et al. Comparative CYP3A4 inhibitory effects of venlafaxine, fluoxetine, sertraline, and nefazodone in healthy volunteers. J Clin Psychopharmacol. 2004;24:4-10.53617 - Inderal LA (propranolol sustained-release) capsules. Baudette, MN: ANI Pharmaceuticals, Inc. 2023 Nov.53671 - Ratcliff SL, Brown A, Rosenberg L. The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient. Burns 2006;32:554-562.55768 - Cardizem (diltiazem tablets) package insert. Bridgewater, NJ: Bridgewater, NJ: Bausch Health US, LLC; 2020 Jun.55990 - Edex (alprostadil for injection) package insert. Lake Forest, Illinois: Actient Pharmaceuticals, LLC; 2015 Mar.56070 - Suprane (desflurane) package insert. Deerfield, IL: Baxter Healthcare Corporation; 2022 Nov.56103 - Verelan (verapamil) capsule package insert. Gainesville GA: Recro Gainesville LLC;2019 Oct.56665 - Hetlioz (tasimelteon) package insert. Washington, D.C.: Vanda Pharmaceuticals, Inc.; 2020 Dec.56699 - De Leersnyder H, Bresson JL, de Blois MC, et al. Beta 1-adrenergic antagonists and melatonin reset the clock and restore sleep in a circadian disorder, Smith-Magenis syndrome. J Med Genet 2003;40:74-8.56853 - Hemangeol (propranolol hydrochloride) oral solution package insert. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; 2021 Jun.57094 - Zykadia (ceritinib) package insert. Indianapolis, IN: Novartis; 2021 Oct.57272 - Baclofen tablet package insert. Philadelphia, PA: Lannett Company, Inc.; 2016 Mar.57741 - Orbactiv (oritavancin) package insert. Lincolnshire, IL: Melinta Therapeutics, LLC; 2022 Jan.57803 - Cerdelga (eliglustat) capsules. Waterford, Ireland: Genzyme Ireland, Ltd.;2018 Sept.58000 - Tybost (cobicistat) package insert. Foster City, CA: Gilead Sciences, Inc; 2021 Sept.58220 - Bachmakov I, Werner U, Endress B, et al. Characterization of beta-adrenoceptor antagonists as substrates and inhibitors of the drug transporter P-glycoprotein. Fundam Clin Pharmacol 2006;20:273-82.58664 - Viekira Pak (ombitasvir; paritaprevir; ritonavir; dasabuvir) tablet package insert. North Chicago, IL: AbbVie, Inc; 2019 Dec.59430 - Corlanor (ivabradine) package insert. Thousand Oaks, CA: Amgen Inc.; 2021 Aug.59891 - Orkambi (lumacaftor; ivacaftor) tablet package insert. Boston, MA: Vertex Pharmaceuticals, Inc. 2023 August59949 - Rexulti (brexpiprazole) tablets package insert. Rockville, MD: Otsuka America Pharmaceutical Inc; 2023 May.60070 - Evekeo (amphetamine sulfate tablets) package insert. Atlanta, GA: Arbor Pharmaceuticals, LLC: 2019 Apr.60142 - Varubi (rolapitant) package insert. Waltham, MA: Tesaro Inc; 2018 April.60164 - Vraylar (cariprazine capsules) package insert. Madison, NJ:Allergan USA, Inc.; 2022 Dec.60860 - Byvalson (nebivolol and valsartan) tablets package insert. Irvine, CA: Allergan USA, Inc.; 2023 Jun.61608 - Rubraca (rucaparib) package insert. Boulder, CO: Clovis Oncology, Inc; 2022 Dec.61733 - Rhofade (oxymetazoline hydrochloride cream) package insert. Irvine, CA: Allergan; 2017 Jan.62181 - Idhifa (enasidenib) tablet package insert. Summit, NJ: Celgene Corporation; 2023 Dec.62457 - Caraci F, Sultana J, Drago F, et al. Clinically relevant drug interactions with anti-alzheimer's drugs. CNS Neurol Disord Drug Targets 2017;16:501-13.62853 - Amin M, Suksomboon N. Pharmacotherapy of type 2 diabetes mellitus: an update on drug-drug interactions. Drug Saf. 2014;37:903-919.62874 - Erleada (apalutamide) tablets package insert. Horsham, PA: Janssen Products, LP; 2023 Dec.63161 - Lucemyra (lofexidine) tablets package insert. Louisville, KY: US WorldMeds, LLC; 2018 May.63309 - Epidiolex (cannabidiol) oral solution package insert. Palo Alto, CA: Jazz Pharmaceuticals, Inc.; 2023 Oct.63402 - Azedra (iobenguane I-131) injection package insert. New York, NY: Progenics Pharmaceuticals, Inc.; 2018 July.63584 - Vizimpro (dacomitinib) tablet package insert. New York, NY: Pfizer Labs; 2018 Sept.64031 - Mayzent (siponimod) tablets package insert. East Hanover, NJ: Novartis Pharmaceutical Corporation; 2023 Aug.64568 - Inrebic (fedratinib) capsules package insert. Summit, NJ: Celgene Corporation; 2021 Dec.64685 - Reyvow (lasmiditan) tablets package insert. Indianapolis, IN: Eli Lilly and Company; 2022 Sep.64768 - Xcorpi (cenobamate) tablets package insert. Paramus, NJ: SK Life Science, Inc.; 2024 Jan.64910 - Bretylium tosylate injection package insert. Baudette, MN; ANI Pharmaceuticals, Inc.: 2019 Dec.65098 - Isturisa (osilodrostat) tablet package insert. Lebanon, NJ: Recordati Rare Disease, Inc.; 2020 Mar.65169 - Ozanimod (Zeposia) capsules package insert. Princeton, NJ: Celgene Corporation; 2023 Aug.65345 - Greenberg SB, Vender J. The use of neuromuscular blocking agents in the ICU: where are we now? Crit Care Med 2013;41:1332-1344.65377 - Tabrecta (capmatinib) tablets package insert. Novartis Pharmaceuticals Corporation;East Hanover, NJ:2023 March.65637 - Mycapssa (octreotide ) delayed-release capsules package insert. Scotland, UK: Chiasma; 2020 June.66129 - Zokinvy (lonafarnib) capsules package insert. Palo Alto, CA: Eiger BioPharmaceuticals, Inc.; 2020 Nov.66159 - Orladeyo (berotralstat) package insert. Durham, NC; BioCryst Pharmaceuticals, Inc.: 2023 Nov.66527 - Ponvory (ponesimod) tablet package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2023 Aug.66575 - Qelbree (viloxazine) extended-release capsules package insert. Rockville, MD: Supernus Pharmaceuticals, Inc.; 2022 Apr.66812 - Fexinidazole package insert. Bridgewater, NJ: Sanofi-Aventis U.S. LLC; 2021 Dec.66964 - Trudhesa (dihydroergotamine mesylate) nasal spray package insert. Seattle, WA: Impel NeuroPharma, Inc.; 2021 Sep.67472 - Jusko WJ, Schentag JJ, Clark JH, et al. Enhanced biotransformation of theophylline in marijuana and tobacco smokers. Clin Pharmacol Ther 1978;24:406-410.67473 - Arellano AL, Papaseit E, Romaguera A, et al. Neuropsychiatric and general interactions of natural and synthetic cannabinoids with drugs of abuse and medicines. CNS Neurol Disord - Drug Targets 2017;16:554-566.67474 - Stout SM, Cimino NM. Exogenous cannabinoids as substrates, inhibitors, and inducers of human drug metabolizing enzymes: a systematic review. Drug Metab Rev 2014;46:86-95.67509 - Igalmi (dexmedetomidine) sublingual film package insert. New Haven, CT: BioXcel Therapeutics, Inc.; 2022 Apr.67543 - Camzyos (mavacamten) package insert. Princeton, NJ: Bristol-Myers Squibb; 2023 Jun.67633 - Walle T, Walle UK, Cowart TD, Conradi EC, Gaffney TE. Selective induction of propranolol metabolism by smoking: additional effects on renal clearance of metabolites. J Pharmacol Exp Ther. 1987 Jun;241(3):928-33.68137 - Mulsant BH, Foglia JP, Sweet RA, Rosen J, Lo KH, Pollock BG. The effects of perphenazine on the concentration of nortriptyline and its hydroxymetabolites in older patients. J Clin Psychopharmacol. 1997 Aug;17(4):318-21.68325 - Krazati (adagrasib) tablets package insert. San Diego, CA: Mirati Therapeutics, Inc.; 2022 Dec.68851 - RizaFilm (rizatriptan) oral film package insert. Saint-Laurent, Quebec, Canada: IntelGenx Corp.; 2023 Dec.69114 - Velsipity (etrasimod) package insert. New York, NY: Pfizer, Inc.; 2023 June69127 - Litfulo (ritlecitinib) package insert. New York, NY: Pfizer Inc.; 2023 Jun69896 - Truqap (capivasertib) tablets package insert. Wilmington, DE; AstraZeneca Pharmaceuticals LP: 2023 Nov.

Monitoring Parameters

  • blood pressure
  • heart rate

US Drug Names

  • HEMANGEOL
  • Inderal
  • Inderal LA
  • Inderal XL
  • InnoPran XL
;