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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
If you suffer from serious stage fright or social anxiety, you may get prescribed a drug called propranolol to help manage symptoms.
Originally developed to alleviate chest pain associated with heart disease, propranolol is mainly used to manage or prevent conditions including atrial fibrillation, high blood pressure (hypertension), and migraine (Srinivasan, 2019).
Propranolol, also found under the brand name Inderal, falls into a class of drugs called beta blockers, which help slow down your heart rate and reduce blood pressure by blocking hormones like adrenaline (AHA, 2020).
Because propranolol is so effective at reducing certain symptoms associated with anxiety—like sweating and rapid heartbeat—it is sometimes used for things like performance anxiety or stage fright (Srinivasan, 2019). Here’s what you need to know about propranolol, its side effects, and how the drug is used for anxiety.
What is propranolol?
Propranolol (brand name Inderal) is a prescription drug used to treat and manage cardiovascular diseases, as well as a variety of other conditions like migraine, essential tremor, and pheochromocytoma—a type of tumor that develops in the adrenal glands above the kidneys (Srinivasan, 2019).
Because the medication reduces blood pressure, which puts less stress on the heart, it is also sometimes prescribed off-label (meaning for a use not officially approved by the U.S. Food and Drug Administration (FDA) to help alleviate symptoms of performance anxiety and social phobias.
And if you’ve ever experienced performance anxiety, you are very familiar with the symptoms: racing heart, clammy hands, feeling like you might throw up. To suppress symptoms like this before a public speaking event or musical performance, for example, a healthcare provider may recommend taking a beta blocker beforehand (Srinivasan, 2019).
Propranolol comes in immediate and extended-release oral tablets, as well as an intravenous injection formula, or in a liquid form for those who have trouble swallowing pills. It comes in dosages of 10 mg, 20 mg, 40 mg, 60 mg, and 80 mg. The extended-release version can be found in higher doses of 120 mg and 160 mg.
Dosages will vary depending on what it’s prescribed for. Extended-release propranolol is taken once daily, and the immediate-release version can be taken 2-4 times per day. Propranolol is only available with a prescription and costs anywhere from $9–$33 for a 30-day supply (GoodRx.com, n.d.).
Aside from its off-label use for social anxiety, propranolol is also FDA approved to treat (FDA, 2010):
- High blood pressure
- Chest pain (angina pectoris)
- Atrial fibrillation: A heart condition that causes an irregular heartbeat (AHA, 2016).
- Heart attack (myocardial infarction)
- Essential tremor: Involuntary moving or shaking of the body that isn’t caused by another medical condition most commonly affecting the hands and more common as we age.
- Hypertrophic obstructive cardiomyopathy (HOCM): Historically known as hypertrophic subaortic stenosis, HOCM is a genetic condition that impacts the wall dividing the left and right sides of the heart (Nishimura, 2017). HOCM causes the wall to abnormally thicken and can lead to sudden death in younger people. Beta blockers are often used to stabilize heart rhythms and alleviate symptoms of HOCM like chest pain, shortness of breath, and dizziness.
- Pheochromocytoma: A rare tumor that appears in the adrenal glands
Anxiety chest pain: is it just in your head?
Side effects of propranolol
Propranolol carries a black box FDA warning, which means it has serious or life-threatening risks if used improperly (FDA, 2010). Stopping this drug suddenly can lead to chest pain or even a heart attack—do not stop taking propranolol without speaking to a healthcare professional.
Here are some of the most common side effects of propranolol (DailyMed, 2019):
- Dizziness or lightheadedness
- Abdominal pain
- Nausea, vomiting, and diarrhea
- Dry eyes
- Changes in mood
- Tingling hands
- Shortness of breath, wheezing, or a cough
- Sexual dysfunction
Less common but more severe adverse reactions to propranolol include low blood pressure, decreases in blood sugar levels, severe allergic reactions, and bradycardia, which is when the heart rate drops too low resulting in dizziness, fainting, fatigue, and chest pain.
Propranolol can also mask symptoms of other health conditions. For example, it may mask signs of hypoglycemia (low blood sugar) in people who are diabetic; when blood sugar levels are too low for too long, seizures and even death can occur.
Beta blockers may also mask symptoms of hyperthyroidism (when your body produces excess thyroid hormones), which can lead to thyroid storm, a condition where heart rate and blood pressure can skyrocket to deadly levels. Propranolol can also worsen other underlying conditions, including heart failure and lung disease.
Sexual dysfunction: what is it, causes, treatments
Propranolol interacts with hundreds of medications, some mild and others severe. Here are some of the major drug interactions to be aware of (FDA, 2010):
- Drugs affecting the cytochrome P-450 system: Propranolol is broken down in the liver by the P-450 system. When taken with other drugs that impact this system, propranolol levels in the body can be too high or too low. Examples of these medications include cimetidine, fluconazole, and fluoxetine (brand name Prozac; see Important Safety Information).
- Antiarrhythmics: These drugs affect heart rhythm, and combined with propranolol, can raise the risk of side effects. Common antiarrhythmic drugs include amiodarone, digoxin, lidocaine, propafenone, and quinine.
- Calcium channel blockers: Propranolol also increases the risk for side effects, like low blood pressure and slow heart rate, when taken at the same time as certain calcium channel blockers. Examples include: diltiazem, nicardipine, nisoldipine, nifedipine, and verapamil.
- Migraine medication: Propranolol raises concentration levels of the migraine medications zolmitriptan or rizatriptan if taken together.
- Blood pressure drugs: The effects of medications used to lower blood pressure, such as alpha blockers or angiotensin-converting enzyme (ACE) inhibitors, are enhanced when taken with propranolol, causing blood pressure to drop too far. Examples include: doxazosin, enalapril, lisinopril, prazosin, and terazosin.
- Theophylline: This drug is known as a bronchodilator, which is used to treat lung issues like asthma. If taken with propranolol, the effects of theophylline may be reduced.
- Diazepam: Available under the brand name Valium, diazepam is used to relieve symptoms of anxiety. Propranolol increases levels of diazepam in the body, which also increases the risk of side effects.
- High cholesterol medication: Certain cholesterol medications can lower levels of propranolol in the body, and vice versa. Medications to be aware of include
- Monoamine oxidase inhibitors (MAOIs): This group of drugs is used for treating depression and other conditions. Taking MAOIs with propranolol could raise the risk of side effects. Types of MAOIs are isocarboxazid, phenelzine, selegiline, and tranylcypromine.
- Warfarin: Warfarin is a medication that prevents blood clots from forming. When combined with propranolol, the levels of warfarin may increase in the body and increase your chance of bleeding.
- Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs help with pain and inflammation. However, they can decrease the effectiveness of propranolol; examples of NSAIDs include naproxen and ibuprofen.
- Alcohol: Drinking alcohol while taking propranolol can raise the risk for side effects, such as dizziness and fatigue.
This doesn’t include the whole list of drugs that can interact with propranolol. Tell your healthcare provider about any medications you are taking before starting treatment with propranolol.
What is propranolol used for?
Who should not take propranolol
There are certain groups of people who should use caution while taking propranolol, and there are others who should not take it at all. Propranolol can worsen conditions—including heart failure, liver disease, myasthenia gravis (a disorder that causes muscle weakness), kidney disease, and circulation-related diseases, such as peripheral vascular disease or Raynaud’s disease—and should be taken with caution (FDA, 2010).
Other at-risk groups include people living with diabetes, bradycardia (slow heart rate), and low blood pressure. People with lung conditions like asthma, emphysema, or chronic obstructive pulmonary disease (COPD) should avoid taking this drug. There isn’t enough research yet on whether propranolol is safe for women who are pregnant. If you are nursing, consult with your healthcare provider before using this medication as it has been found to reach breastmilk (FDA, 2010).
Whether you’re taking propranolol for anxiety or high blood pressure, lifestyle changes can also boost your overall health. Stopping smoking, exercising regularly, eating nutritiously, and managing stress are all ways to help reduce symptoms of anxiety and keep your heart healthy.
- American Heart Association (AHA). (2015). Angina (Chest Pain). Retrieved Oct. 20, 2020 from https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain
- American Heart Association (AHA). (2020). Cardiac Medications. Retrieved Oct. 20, 2020 from https://www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack/cardiac-medications#beta
- American Heart Association (AHA). (2016). What is Atrial Fibrillation (AFib or AF)? Retrieved Oct. 20, 2020 from https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af
- Centers for Disease Control and Prevention (CDC). (2020). Estimated Hypertension Prevalence, Treatment, and Control Among U.S. Adults. Retrieved on Oct. 21, 2020 from https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html
- DailyMed. (2019). Propranolol hydrochloride capsule. Retrieved Oct. 20,, 2020 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8efc9fc6-6db0-43c9-892b-7423a9ba679f
- Dezsi, C. A., & Szentes, V. (2017). The Real Role of β-Blockers in Daily Cardiovascular Therapy. American Journal of Cardiovascular Drugs, 17(5), 361-373. doi: 10.1007/s40256-017-0221-8. Retrieved from https://link.springer.com/article/10.1007%2Fs40256-017-0221-8
- GoodRx.com. (n.d.) Propranolol. Retrieved Oct. 20, 2020 from https://www.goodrx.com/propranolol
- National Institute of Neurological Disorders. (2020). Tremor Fact Sheet. Retrieved on Oct. 22, 2020 from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Tremor-Fact-Sheet
- National Organization for Rare Disorders (NORD). (n.d.). Pheochromocytoma. Retrieved on Oct. 22, 2020 from https://rarediseases.org/rare-diseases/pheochromocytoma/
- Nishimura, R. A., Seggewiss, H., & Schaff, H. V. (2017). Hypertrophic Obstructive Cardiomyopathy. Circulation Research, 121, 771-783. https://doi.org/10.1161/CIRCRESAHA.116.309348. Retrieved from https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.116.309348
- Srinivasan, A. V. (2019). Propranolol: A 50-Year Perspective. Annals of Indian Academy of Neurology, 22(1), 21-26. https://dx.doi.org/10.4103%2Faian.AIAN_201_18. Retrieved from https://www.annalsofian.org/article.asp?issn=0972-2327;year=2019;volume=22;issue=1;spage=21;epage=26;aulast=Srinivasan
- U. S. Food and Drug Administration (FDA). (2010). Inderal (propranolol hydrochloride) tablets. Retrieved on Oct. 20, 2020 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/016418s080,016762s017,017683s008lbl.pdf
- Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., et al. (2020). Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association. Circulation, 141, 139-596. https://doi.org/10.1161/CIR.0000000000000757. Retrieved from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000757
Yael Cooperman is a physician and works as a Senior Manager, Medical Content & Education at Ro.