propranolol

Adjunctive therapy

Brands: INDERAL, INDERAL LA

Last reviewed 2025-12-29

Reviewed by PsychMed Editorial Team.

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Quick answers

What is propranolol?
Propranolol (brand Inderal) is a nonselective beta blocker indicated for cardiovascular and neurologic conditions (e.g., hypertension, angina, atrial fibrillation rate control, migraine prophylaxis, essential tremor). In psychiatry it is most commonly used off label for performance anxiety and for antipsychotic-associated akathisia.
What is INDERAL?
INDERAL is a brand name for propranolol (other brands: INDERAL LA).
What is INDERAL (propranolol) used for?
Label indications include: Hypertension; angina pectoris; atrial fibrillation ventricular rate control; post-MI mortality reduction; migraine prophylaxis; essential tremor; hypertrophic subaortic stenosis; pheochromocytoma adjunct (label).
What drug class is INDERAL (propranolol)?
Nonselective beta-adrenergic receptor blocker (beta-1/beta-2 antagonism).
What strengths does INDERAL (propranolol) come in?
Immediate-release tablets: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg.

Snapshot

Class: Adjunctive therapy
Common US brands: INDERAL, INDERAL LA
Therapeutic drug monitoring not routinely recommended.
Last reviewed: 2025-12-29

Label indications

Hypertension; angina pectoris; atrial fibrillation ventricular rate control; post-MI mortality reduction; migraine prophylaxis; essential tremor; hypertrophic subaortic stenosis; pheochromocytoma adjunct (label).

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Clinical Highlights

Propranolol (brand Inderal) is a nonselective beta blocker indicated for cardiovascular and neurologic conditions (e.g., hypertension, angina, atrial fibrillation rate control, migraine prophylaxis, essential tremor). In psychiatry it is most commonly used off label for performance anxiety and for antipsychotic-associated akathisia. Propranolol works best for the “body symptoms” of anxiety (tremor, tachycardia, sweating) rather than the cognitive symptoms (worry, rumination). It is not a first-line long-term treatment for generalized anxiety disorder.

Safety hinges on cardiopulmonary screening: avoid in bronchial asthma, significant bradycardia, or heart block; monitor for hypotension and fatigue and counsel patients about dizziness and exercise intolerance.
Beta blockers can mask hypoglycemia symptoms; use extra caution in diabetes, older adults, and when other rate-lowering drugs are present.
The compare view and the propranolol evidence feed can help balance sedation and physiologic risk, and the propranolol print page can support safe-use counseling.
Evidence for beta blockers in anxiety disorders is mixed; treat them as situational adjuncts, not a replacement for CBT, SSRI/SNRI strategies, or sleep interventions when symptoms are persistent.
Avoid abrupt discontinuation in patients with coronary disease or angina risk; taper when stopping after sustained use (label).

Dosing & Formulations

Tablets: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (label). Performance anxiety (off label): low single doses taken before a time-limited event are common; start low and confirm tolerability with a trial dose (monitor heart rate, blood pressure, and dizziness).

Akathisia (off label): dosing strategies vary; use the lowest effective dose and reassess response alongside antipsychotic dose adjustments.
Extended-release propranolol products exist for medical indications; do not substitute ER for IR without confirming equivalence and monitoring.

Monitoring & Risks

Bradycardia and hypotension: monitor heart rate, orthostasis, and syncope risk, especially during titration. Bronchospasm: avoid in asthma and use caution in COPD or reactive airway disease (label).

Fatigue, sleep disturbance, and depressive symptoms can occur; reassess if mood worsens or daytime function declines.
In diabetes, propranolol may mask adrenergic warning signs of hypoglycemia; counsel patients and coordinate with medical teams.

Drug Interactions

Additive bradycardia/hypotension with other rate-lowering agents (verapamil, diltiazem, digoxin) and with antihypertensives. CYP-mediated interactions: strong CYP2D6 inhibitors (e.g., fluoxetine, paroxetine) and other enzyme modulators can increase propranolol exposure; monitor for bradycardia and dizziness (label).

Alcohol and sedatives can amplify dizziness and fall risk, especially when the patient is beta-blocked.

Practice Notes

Use targeted prescriptions (event-limited or symptom-triggered plans) and avoid “PRN forever” patterns that bypass clinical reassessment. For akathisia, also address the underlying driver (antipsychotic dose, timing, or agent choice) rather than escalating propranolol alone.

If anxiety is persistent and impairing, prioritize psychotherapy and SSRI/SNRI strategies; use propranolol for short, specific situations.
Document contraindication screening (asthma, conduction disease, bradycardia) and ensure patients know when to hold doses for low heart rate or dizziness.

References

Propranolol hydrochloride tablets prescribing information — DailyMed (2025)
Propranolol for the treatment of anxiety disorders — Journal of Psychopharmacology (2016)
Beta Blockers FOR THE Treatment OF Anxiety Disorders — Journal of Affective Disorders (2025)
Neuroleptic Induced Akathisia — Propranolol Versus Benztropine — Biological Psychiatry (1988)