Propranolol should not be taken by anyone with asthma, COPD, or other reactive airway disease, a resting heart rate below about 55, second or third degree heart block, sick sinus syndrome, decompensated heart failure, low blood pressure, an existing beta-blocker prescription, a prior adverse reaction to a beta-blocker, or during pregnancy and breastfeeding. Insulin-treated or sulfonylurea-treated diabetes, Raynaud's phenomenon, thyroid disease, liver disease, myasthenia gravis, rizatriptan use, and any cardiac history require a physician's review before propranolol is prescribed.
TL;DR: Propranolol is a safe old drug for most people and a dangerous one for some. Do not take it if you have asthma, COPD, or any breathing condition that needs an inhaler. Do not take it if your resting heart rate runs under about 55, if you have heart block or a pacemaker, if you have heart failure, if your blood pressure runs low, or if you already take a beta-blocker, including glaucoma eye drops. Skip it in pregnancy and breastfeeding. Tell your doctor before you take it if you use insulin or a sulfonylurea, have Raynaud's, thyroid or liver disease, myasthenia gravis, take rizatriptan for migraine, or have any heart history. Every one of those changes what a doctor should do. If you are unsure which applies to you, write it down and send it to Dr. Ash.
Most pages about propranolol give the safety list a paragraph near the bottom. This one is the whole page, because it is the part of the decision a physician is paid for and it is the part an online form is worst at.
Each item below carries the reason it is on the list. If you understand why an answer matters, you are far more likely to give the true one, and the true one is what makes this safe.
Which conditions rule propranolol out?
These are the answers where the correct response is no, regardless of how much you want the prescription. Performance anxiety is an elective indication, which means there is no clinical emergency on the other side of the scale to justify a risk.
Asthma, COPD, emphysema, or any reactive airway disease. Propranolol is non-selective, so it blocks the beta-2 receptors that keep your airways open. In someone with reactive airways that can trigger bronchospasm, and a severe attack can be fatal. A drug taken to make a presentation go well cannot carry that risk. This includes anyone who keeps a rescue inhaler for exercise-induced symptoms, and anyone who had childhood asthma and is unsure whether it went away.
A resting heart rate below about 55, or known bradycardia. Propranolol lowers heart rate. Lowering an already low rate can produce dizziness, fainting, and in the wrong heart a dangerous pause.
Second or third degree heart block, sick sinus syndrome, or a pacemaker. These are conduction problems, and propranolol slows conduction through the AV node. That is the mechanism the drug is used for in some arrhythmias and the mechanism that makes it hazardous in these.
Decompensated heart failure, or a reduced ejection fraction that has not been stabilized. Beta-blockers are a cornerstone of chronic heart failure treatment, started carefully at low doses by a cardiologist and titrated over months. An occasional 20mg tablet taken before a wedding toast is a different thing.
Low blood pressure, or a history of fainting. If your pressure already runs low, taking more of it away before you stand up in front of a room is the wrong direction.
An existing beta-blocker. Metoprolol, atenolol, carvedilol, bisoprolol, nebivolol, labetalol, and the timolol in many glaucoma eye drops all count. Eye drops are absorbed systemically and are the one people forget.
A previous adverse reaction to a beta-blocker. Wheezing, fainting, or a marked drop in rate on a previous beta-blocker predicts the same on this one.
Pregnancy, trying to conceive, or breastfeeding. Propranolol crosses the placenta and appears in breast milk. There are pregnancies where a beta-blocker is the right treatment, prescribed and monitored for a specific reason. Situational nerves is not one of them.
Age under 18. Situational anxiety in a teenager deserves an assessment instead of a prescription arriving in the post.
Which conditions mean a doctor has to look before anything is prescribed?
This second list does not close the door. It moves the decision to a physician, which is where it belonged in the first place, and often the answer is yes with a modification.
Diabetes treated with insulin or a sulfonylurea. This is the one I care about most. The early warning signs of a falling blood glucose, the tremor, the pounding heart, the sweating, are adrenaline symptoms, and propranolol blocks them. The low still happens. You simply stop being told about it, and you find out later and lower. Beta-blockade can also blunt the counter-regulatory response that would pull you back up. If you use insulin and this drug is right for you, you need a plan for that specific risk, and that plan is a conversation.
Raynaud's phenomenon or peripheral vascular disease. Beta-2 blockade in the peripheral vessels makes cold hands colder, and Raynaud's typically worsens.
Thyroid disease. Propranolol masks the adrenergic signs of hyperthyroidism, which can hide a thyroid problem that is getting worse. It is also used deliberately to treat those symptoms, which is why an unmonitored prescription can obscure the picture.
Liver disease. Propranolol is cleared by the liver, so impaired function raises the level in your blood from the same tablet.
Myasthenia gravis. Beta-blockers can worsen muscle weakness.
Any cardiac history at all. Prior heart attack, a stent, an arrhythmia, a murmur that was being followed, or an abnormal EKG someone once mentioned. Any of those means the person prescribing needs the record instead of a checkbox.
Rizatriptan and other triptans. Propranolol raises rizatriptan levels substantially, and the migraine dose has to be reduced. Anyone taking a triptan needs this reviewed, not assumed.
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Other blood pressure or rhythm medicines, including calcium channel blockers like verapamil and diltiazem, which compound the effect on rate and conduction.
Psychiatric medicines. Several antidepressants and antipsychotics share liver enzymes with propranolol and can raise its level, and some carry their own effects on heart rate and rhythm.
A diagnosed anxiety disorder, or anxiety on most days. This is not a safety problem. It is a diagnosis problem, and it is the most common reason to say no. A drug for a moment is the wrong treatment for a condition that arrives every day.
Age over 65. Older adults are more sensitive to drops in heart rate and blood pressure, and falls carry consequences that a younger person's dizziness does not.
Guidance from the Clinic
What if a service offers me a different beta-blocker because of my asthma?
Cardioselective beta-blockers such as atenolol, metoprolol, and bisoprolol prefer the beta-1 receptors in the heart over the beta-2 receptors in the airways, and they are used in people with mild airway disease when there is a cardiac reason to use them. The Cochrane review of that practice found no measurable fall in lung function in mild to moderate disease.
That evidence does not carry over to this. Selectivity is relative and weakens as the dose climbs. Every patient in those trials had a cardiac indication that justified accepting some risk. A job interview does not supply one. Fishtown Medicine declines beta-blockade for performance anxiety in anyone with reactive airway disease instead of offering a cardioselective substitute, and if a service offers you one off a web form, a judgment has been made on your behalf that you were never shown.
What should I do if I already took propranolol and something felt wrong?
Stop and get assessed. Wheezing, chest tightness, or shortness of breath after a dose needs urgent attention, and if you have a rescue inhaler, use it and seek care. Fainting, a heart rate you can feel is far too slow, or chest pain are emergency symptoms: in the United States, call 911.
Milder effects, lightheadedness on standing, unusual tiredness, cold hands, do not need an emergency room and do need a conversation before you take another one. That is one of the reasons the first dose belongs at home on an ordinary day, well before anything depends on it.
If you have been taking a beta-blocker every day for months, do not stop abruptly on your own. Sudden withdrawal can cause rebound tachycardia and angina, and a taper is simple when a clinician plans it.
Why does this page exist when others do not have one?
Because the decline is the product. Any service can send a cheap generic to somebody who filled in a form. The medicine costs a few dollars, so what a patient is buying is the judgment about whether it belongs in their body, and that judgment is only worth something if a no is as available as a yes.
Fishtown Medicine charges for the evaluation whether or not it ends in a prescription, and tells you the reason when the answer is no, along with what would help instead. A service that charges only on approval has arranged its incentives so that a careful decline costs it money, and incentives like that show up in decisions eventually.
The companion pages cover the rest: propranolol for performance anxiety has the dose, timing, and evidence, and performance anxiety starts with what your body is doing and why.
Key Takeaways
- Asthma and reactive airway disease are the firmest stop on the list, and a cardioselective substitute is not a safe route around them for an elective indication.
- Slow heart rate, heart block, heart failure, low blood pressure, and any existing beta-blocker, including glaucoma eye drops, all rule it out.
- Insulin and sulfonylurea use is the highest-stakes conversation, because propranolol removes the warning signs of a low while the low still happens.
- Anxiety on most days is a diagnosis problem instead of a safety problem, and it is the commonest reason a careful clinician says no.
- A service that charges only when it approves you has made the careful no cost it money, and that is useful to know before you hand over a form.
Related at Fishtown Medicine
- Propranolol for performance anxiety
- Performance anxiety: what your body is doing
- A beta-blocker or a benzodiazepine?
- Propranolol side effects
- Propranolol and alcohol
- When blood pressure medication stops working
Scientific References
- US Food and Drug Administration. Inderal (propranolol hydrochloride) prescribing information. FDA Access Data.
- Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for reversible airway disease. Cochrane Database of Systematic Reviews. 2005;(4):CD002992.
- Cruickshank JM. Beta-blockers and diabetes: the bad guys come good. Cardiovascular Drugs and Therapy. 2002;16(5):457-470.
- Nelson WL, Fraunfelder FT, Sills JM, Arrowsmith JB, Kuritsky JN. Adverse respiratory and cardiovascular events attributed to timolol ophthalmic solution. American Journal of Ophthalmology. 1986;102(5):606-611.
- Merck. Maxalt (rizatriptan benzoate) prescribing information, propranolol interaction. FDA Access Data.
- Cryer PE. Mechanisms of hypoglycemia-associated autonomic failure in diabetes. New England Journal of Medicine. 2013;369(4):362-372.
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