Stahl's Essential Psychopharmacology Online
In Collaboration With
Propranolol
Therapeutics
Brands
• Inderal, Inderal-LA, InnoPran XL
Generic?
Yes
Class
• Antihypertensive, beta-blocker (non-selective)
Commonly Prescribed for
(FDA approved in bold)
• Migraine prophylaxis
• Essential tremor
• Hypertension
• Angina pectoris due to coronary atherosclerosis
• Cardiac arrhythmias (including supraventricular arrhythmias, ventricular tachycardia, digitalis intoxication)
• Myocardial infarction
• Hypertrophic subaortic stenosis
• Pheochromocytoma
• Akathisia (antipsychotic induced)
• Parkinsonian tremor
• Congestive heart failure
• Tetralogy of Fallot
• Hyperthyroidism (adjunctive)
• Generalized anxiety disorder
• Post-traumatic stress disorder
• Prevention of variceal bleeding
How the Drug Works
• Migraine:
Proposed mechanisms include inhibition of adrenergic pathway,
interaction with serotonin system and receptors, inhibition
of nitric oxide production, and
normalization of contingent negative variation. Prevention of cortical
spreading depression
may be the mechanism of action for
all migraine preventives
• Tremor: effectiveness is likely due to peripheral beta-2 receptor antagonism
How Long Until It Works
• Migraines - within 2 weeks, but can take up to 3 months on a stable dose to see full effect
• Tremor - within days
If It Works
• Migraine - goal is a 50% or greater decrease in migraine frequency or severity. Consider tapering or stopping if headaches
remit for more than 6 months or if considering pregnancy
• Tremor - reduction in the severity of tremor, allowing greater functioning with daily activities and clearer speech
If It Doesn't Work
• Increase to highest tolerated dose
• Migraine: Address other issues, such as medication overuse, other coexisting medical disorders, such as anxiety, and consider
changing to another drug or adding a second drug
• Tremor:
Coadministration with primidone up to 250 mg/day can augment
response. Second-line medications include benzodiazepines,
such as clonazepam, gabapentin,
topiramate, methazolamide, nadolol, and botulinum toxin (useful for
voice and hand tremor.)
For truly refractory patients,
thalamotomy or deep brain stimulation of the ventral intermediate
nucleus of the thalamus are
options
• Alternatives for tremor include hand weights and eliminating caffeine. Low doses of alcohol reduce tremor, but is not generally
recommended
Best Augmenting Combos for Partial Response or Treatment-Resistance
• Migraine:
For some patients, low-dose polytherapy with 2 or more drugs may be
better tolerated and more effective than high-dose
monotherapy. May use in combination
with AEDs, antidepressants, natural products, and non-pharmacologic
treatments, such as
biofeedback, to improve headache
control
• Tremor: Can use in combination with primidone or second-line medications
Tests
• None required