Section 3.6.2

Propranolol (Beta - Blockers)

General Description

Propranolol (Inderal) is an antihypertensive medication that has been used for off-label purpose in psychiatry for many years. It is a non-selective B-adrenergic receptor blocking agent that inhibits responses to adrenergic stimuli.

Indications for Medication

Treatment of akathisia in absence of other EPS: violent outbursts, especially in patients with organic brain syndromes, autonomic symptoms associated with generalized anxiety and panic attacks, performance anxiety (a form of social phobia) and lithium tremor.

Clinical Guidelines

The therapeutic range for propanolol is usually 10-200mg a day in divided doses. Patients may be started on a dose of 10mg TID and slowly increased by 20-30mg per day until therapeutic effect is achieved. Consider increasing the daily dose if symptoms being treated are unrelieved and patient is tolerating drug. Evidence of hypotension (BP< 90/60 MM Hg) and/or bradycardia (HR < 55) would preclude increases.

For performance anxiety, a single dose of 10-40mg may be used 20 to 30 minutes prior to anxiogenic event. For lithium tremor, 20-160mg/day may be used in 2-3 divided doses. For neuroleptic-induced akathisia, 30-80mg/day may be used in divided doses. For violent outbursts in patients with organic brain syndromes, 40-520mg/day may be used in 2-4 divided doses. For generalized anxiety and panic disorder, 40-320mg/day may be used in 2-3 divided doses

Adverse Effects

Possible cardiovascular side effects include hypotension, bradycardia, dizziness and congestive failure (in patients with compromised myocardial function). Additionally, there is a "withdrawal syndrome" that may include rebound worsening of preexisting angina pectoris when beta-blockers are discontinued.

Other potential side effects include bronchospasm (asthma worsening), worsened hypoglycemia in diabetics on insulin or oral agents, nausea, diarrhea, abdominal pain, impotence, fatigue, dysphoria, depression, insomnia, vivid nightmares, or psychosis (rare).

Laboratory values may be altered such as increased BUN/creatinine, increased LDH, alkaline phosphatase or serum aminotransferases.

Rare side effects may include Raynaud?s phenomenon or Peyronie?s Disease. The use of propranolol may mask signs of thyrotoxicosis.

Drug-Drug Interactions

Propranolol may increase plasma levels of diazepam. When used with phenothiazines, there may be increased plasma levels and effect of both drugs. There was a case report of hypotension and cardiopulmonary arrest with co-administration of haldol and propranolol.

The consent form for this medication is "Non-psychoactive Medications for Psychiatric Conditions."