Propranolol

Not to be confused with Profadol, Propanol, or Propofol.
Propranolol (INN)
Systematic (IUPAC) name
(RS)-1-(1-methylethylamino)-3-(1-naphthyloxy)propan-2-ol
Clinical data
Trade names Inderal
AHFS/Drugs.com monograph
Licence data US FDA:link
Pregnancy
category
  • AU: C
  • US: C (Risk not ruled out)
Legal status
Routes of
administration		 By mouth, rectal, IV
Pharmacokinetic data
Bioavailability 26%
Metabolism Liver (extensive) 1A2, 2D6; minor: 2C19, 3A4
Biological half-life 4–5 hours
Excretion Kidney (<1%)
Identifiers
CAS Number 525-66-6 YesY
ATC code C07AA05
PubChem CID 4946
IUPHAR/BPS 564
DrugBank DB00571 YesY
ChemSpider 4777 YesY
UNII 9Y8NXQ24VQ YesY
KEGG D08443 YesY
ChEBI CHEBI:8499 YesY
ChEMBL CHEMBL27 YesY
Chemical data
Formula C16H21NO2
Molar mass 259.34 g/mol
Chirality 1 : 1 mixture (racemate)
  (verify)

Propranolol is a medication of the beta blocker type.[1] It is used to treat high blood pressure, a number of types of irregular heart rate, thyrotoxicosis, capillary hemangiomas, performance anxiety, and essential tremors.[1][2][3] It is used to prevent migraine headaches, and to prevent further heart problems in those with angina or previous heart attacks.[1] It can be taken by mouth or by injection into a vein. The formulation that is taken by mouth comes in short acting and long acting versions. Maximum effect when taken by mouth typically occurs within 90 minutes.[1]

Common side effects include nausea, abdominal pain, and constipation. It should not be used in those with an already slow heart rate and most of those with heart failure. Quickly stopping the medication in those with coronary artery disease may worsen symptoms. It may worsen the symptoms of asthma. Greater care is recommended in those with liver or kidney problems.[1] Propranolol may possibly cause harmful effects in the baby if taken during pregnancy.[4] Its use during breastfeeding is likely okay but the baby should be monitored for side effects.[5] It is a nonselective beta blocker which works by blocking β-adrenergic receptors.[1]

Propranolol was discovered in 1964.[6][7] It is on the World Health Organization's List of Essential Medicines, the most important medications needed in a basic health system.[8] Propranolol is available as a generic medication.[1] The wholesale cost is between 0.24 and 2.16 USD per month.[9] In the United States it costs about 15 USD per month at a typical dose.[1]

Medical uses

An 80 mg capsule of extended-release propranolol
A mixture of 20 mg and 10 mg propranolol tablets

Heart disease

Propranolol is used for treating various conditions, including:

Propranolol is not recommended for the treatment of hypertension by the Eighth Joint National Committee (JNC 8) because a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to an angiotensin receptor blocker was noted in one study.[11]

Propranolol is also used to lower portal vein pressure in portal hypertension and prevent esophageal variceal bleeding and ascites.

Psychological

It is occasionally used to treat performance anxiety.[2] Evidence to support the use in other anxiety disorders is poor.[12]

Propranolol is being investigated as a potential treatment for post-traumatic stress disorder (PTSD).[17][18] Propranolol works to inhibit the actions of norepinephrine, a neurotransmitter that enhances memory consolidation. Individuals given propranolol immediately after trauma experienced fewer stress-related symptoms and lower rates of PTSD than respective control groups who did not receive the drug.[19]

It has been studied for improvement of social communication skills in people with autism spectrum disorder.[20]

Ethical and legal questions have been raised surrounding the use of propranolol-based medications for use as a "memory damper", including: altering memory-recalled evidence during an investigation, modifying behavioral response to past (albeit traumatic) experiences, the regulation of these drugs, and others.[21] However, Hall and Carter have argued that many such objections are "based on wildly exaggerated and unrealistic scenarios that ignore the limited action of propranolol in affecting memory, underplay the debilitating impact that PTSD has on those who suffer from it, and fail to acknowledge the extent to which drugs like alcohol are already used for this purpose."[22]

Other

Propranolol may be used to treat severe infantile hemangiomas (IHs). This treatment shows promise as being superior to corticosteroids when treating IHs. Extensive clinical case evidence and a small controlled trial support its efficacy.[27]

Adverse effects

Due to the high penetration across the blood-brain barrier, lipophilic beta blockers such as propranolol and metoprolol are more likely than other less lipophilic beta blockers to cause sleep disturbances such as insomnia and vivid dreams, and nightmares.[28]

Adverse drug reactions (ADRs) associated with propranolol therapy are similar to other lipophilic beta blockers.

Precautions and contraindications

Propranolol should be used with caution in people with:[29]

Propranolol is contraindicated in patients with:[29]

Pregnancy and lactation

Propranolol, like other beta blockers, is classified as pregnancy category C in the United States and ADEC category C in Australia. β-blocking agents in general reduce perfusion of the placenta which may lead to adverse outcomes for the neonate, including pulmonary or cardiac complications, or premature birth. The newborn may experience additional adverse effects such as hypoglycemia and bradycardia.[30]

Most β-blocking agents appear in the milk of lactating women. However, propranolol is highly bound to proteins in the bloodstream and is distributed into breast milk at very low levels.[31] These low levels are not expected to pose any risk to the breastfeeding infant, and the American Academy of Pediatrics considers propranolol therapy "generally compatible with breastfeeding".[30][31][32][33]

Interactions

Since beta blockers are known to relax the cardiac muscle and to constrict the smooth muscle, these beta-adrenergic antagonists, including propranolol, have an additive effect with other drugs which decrease blood pressure, or which decrease cardiac contractility or conductivity. Clinically significant interactions particularly occur with:[29]

Pharmacokinetics

Propranolol is rapidly and completely absorbed, with peak plasma levels achieved about 1–3 hours after ingestion. Coadministration with food appears to enhance bioavailability.[35] Despite complete absorption, propranolol has a variable bioavailability due to extensive first-pass metabolism. Hepatic impairment therefore increases its bioavailability. The main metabolite 4-hydroxypropranolol, with a longer half-life (5.2–7.5 hours) than the parent compound (3–4 hours), is also pharmacologically active.

Propranolol is a highly lipophilic drug achieving high concentrations in the brain. The duration of action of a single oral dose is longer than the half-life and may be up to 12 hours, if the single dose is high enough (e.g., 80 mg). Effective plasma concentrations are between 10 and 100 mg/l. Toxic levels are associated with plasma concentrations above 2000 mg/l.

Mechanism of action

Propranolol is a nonselective beta blocker; that is, it blocks the action of epinephrine and norepinephrine on both β1- and β2-adrenergic receptors. It has little intrinsic sympathomimetic activity, but has strong membrane stabilizing activity (only at high blood concentrations, e.g. overdosage). Propranolol has inhibitory effects on the norepinephrine transporter (NET) and/or stimulates norepinephrine release (the concentration of norepinephrine is increased in the synapse).[36] Since propranolol blocks β-adrenoceptors, the increase in synaptic norepinephrine only results in α-adrenergic activation, with the α1-adrenoceptor being particularly important for effects observed in animal models. Therefore, it can be looked upon as an indirect α1 agonist, as well as a β antagonist. Probably owing to the effect at the α1-adrenoceptor, the racemic and the individual enantiomers of propranolol have been shown to substitute for cocaine in rats, with the most potent enantiomer being (S)-(−)-propranolol. In addition, some evidence suggests propranolol may function as a partial agonist at one or more serotonin receptors (possibly 5-HT1B).

Both enantiomers of the drug have a local anesthetic (topical) effect, which is normally mediated by blockade of voltage-gated sodium channels. Few studies have demonstrated propranolol's ability to block cardiac, neuronal, and skeletal voltage-gated sodium channels, accounting for its known "membrane stabilizing effect" and antiarrhythmic and other central nervous system effects.[37][38][39]

History

British scientist James W. Black developed propranolol in the 1960s.[40] In 1988, he was awarded the Nobel Prize in Medicine for this discovery. Propranolol was derived from the early β-adrenergic antagonists dichloroisoprenaline and pronethalol. The key structural modification, which was carried through to essentially all subsequent beta blockers, was the insertion of an oxymethylene group into the aryl ethanolamine structure of pronethalol, thus greatly increasing the potency of the compound. This also apparently eliminated the carcinogenicity found with pronethalol in animal models.

Newer, more cardio-selective beta blockers (such as bisoprolol, nebivolol, carvedilol, or metoprolol) are now used in the treatment of hypertension.

Society and culture

In a 1987 study by the International Conference of Symphony and Opera Musicians, 27% of interviewed members admitted to using beta blockers such as propranolol for musical performances.[41] For about 10–16% of performers, their degree of stage fright is considered pathological.[41][42] Propranolol is used by musicians, actors, and public speakers for its ability to treat anxiety symptoms activated by the sympathetic nervous system.[43] This can be seen as giving participating individuals an unfair advantage, especially in competitions, akin to the use of performance-enhancing drugs in athletes.[44]

Brand names

Original propranolol was marketed in 1965 under the brand name Inderal and manufactured by ICI Pharmaceuticals (now AstraZeneca). Propranolol is also marketed under brand names Avlocardyl, Deralin, Dociton, Inderalici, InnoPran XL, Sumial, Anaprilin, and Bedranol SR (Sandoz). In India it is marketed under brand names such as Ciplar and Ciplar LA by Cipla. Hemangeol, a 4.28 mg/mL solution of propranolol, is indicated for the treatment of proliferating infantile hemangioma.[45]

Research

In 2015, a trial in women with epithelial ovarian cancer showed that the intake of a nonselective β-blocker was associated with a longer survival compared to a β1-selective β-blocker or no β-blocker.[46] Currently, an interventional study is being conducted at the M.D. Anderson Cancer Center to access the feasibility of a nonselective β-blocker plus standard chemotherapy (paclitaxel and carboplatin or possibly docetaxel) to treat ovarian cancer.[47]

References

  1. 1 2 3 4 5 6 7 8 "Propranolol hydrochloride". Monograph. The American Society of Health-System Pharmacists. Retrieved 1 January 2015.
  2. 1 2 Davidson, JR (2006). "Pharmacotherapy of social anxiety disorder: what does the evidence tell us?". The Journal of clinical psychiatry. 67 Suppl 12: 20–6. PMID 17092192.
  3. ↑ Chinnadurai, S; Fonnesbeck, C; Snyder, KM; Sathe, NA; Morad, A; Likis, FE; McPheeters, ML (February 2016). "Pharmacologic Interventions for Infantile Hemangioma: A Meta-analysis.". Pediatrics 137 (2). PMID 26772662.
  4. ↑ "Prescribing medicines in pregnancy database". Australian Government. 3 March 2014. Retrieved 22 April 2014.
  5. ↑ Yaffe, Gerald G. Briggs, Roger K. Freeman, Sumner J. (2011). Drugs in pregnancy and lactation : a reference guide to fetal and neonatal risk (9th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1226. ISBN 9781608317080.
  6. ↑ Russell, RM (January 2004). "The enigma of beta-carotene in carcinogenesis: what can be learned from animal studies.". The Journal of nutrition 134 (1): 262S–268S. PMID 14704331.
  7. ↑ Ravina, Enrique (2011). The evolution of drug discovery : from traditional medicines to modern drugs (1. Aufl. ed.). Weinheim: Wiley-VCH. p. 331. ISBN 9783527326693.
  8. ↑ "WHO Model List of EssentialMedicines" (PDF). World Health Organization. October 2013. Retrieved 22 April 2014.
  9. ↑ "Name". International Drug Price Indicator Guide. Retrieved January 2016.
  10. ↑ Sheetal Ladva (28 June 2006). "NICE and BHS launch updated hypertension guideline". National Institute for Health and Clinical Excellence. Retrieved 11 October 2009.
  11. ↑ Paul A. James, MD; et al. (5 February 2014). "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults". The Journal of the American Medical Association. Retrieved 23 March 2015.
  12. ↑ Steenen, SA; van Wijk, AJ; van der Heijden, GJ; van Westrhenen, R; de Lange, J; de Jongh, A (February 2016). "Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis.". Journal of psychopharmacology (Oxford, England) 30 (2): 128–39. doi:10.1177/0269881115612236. PMID 26487439.
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  20. ↑ "Blood pressure medicine may improve conversational skills of individuals with autism". University of Missouri at Columbia via PsyPost.com. February 1, 2016.
  21. ↑ Kolber, Adam J. (2006). "Therapeutic Forgetting: The Legal and Ethical Implications of Memory Dampening". Vanderbilt Law Review, San Diego Legal Studies Paper No. 07-37. 59: 1561.
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  25. ↑ Eadie, M.; J. H. Tyrer (1985). The Biochemistry of Migraine. New York: Springer. p. 148. ISBN 9780852007310. OCLC 11726870.
  26. ↑ Clinical summary
  27. ↑ Hogeling, M. (2012). "Propranolol for Infantile Hemangiomas: A Review". Current Dermatology Reports: Online-first. doi:10.1007/s13671-012-0026-6.
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  29. 1 2 3 Rossi S, editor. Australian Medicines Handbook 2006. Adelaide: Australian Medicines Handbook; 2006.
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  31. 1 2 [No authors listed] (2007). "Propranolol". In: Drugs and Lactation Database. U.S. National Library of Medicine Toxicology Data Network. Retrieved 25 February 2013.
  32. ↑ [No authors listed] (September 2001). "Transfer of drugs and other chemicals into human milk". Pediatrics 108 (3): 776–89. PMID 11533352.
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  38. ↑ Bankston J. R., Kass R. S. (2010). "Molecular determinants of local anesthetic action of beta-blocking drugs: implications for therapeutic management of long QT syndrome variant 3". J. Mol. Cell. Cardiol 48: 246–253. doi:10.1016/j.yjmcc.2009.05.012.
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  40. ↑ Black JW, Crowther AF, Shanks RG, Smith LH, Dornhorst AC (1964). "A new adrenergic betareceptor antagonist". The Lancet 283 (7342): 1080–1081. doi:10.1016/S0140-6736(64)91275-9. PMID 14132613.
  41. 1 2 Fishbein M, Middlestadt SE, Ottati V, Straus S, Ellis A (1988). "Medical problems among ICSOM musicians: overview of a national survey". Med Probl Perform Artist 3: 1–8.
  42. ↑ Steptoe A, Malik F, Pay C, Pearson P, Price C, Win Z (1995). "The impact of stage fright on student actors". Br J Psychol 86: 27–39. doi:10.1111/j.2044-8295.1995.tb02544.x.
  43. ↑ Alan H. Lockwood (1989). "Medical Problems of Musicians". NEJM 320 (4): 221–227. doi:10.1056/nejm198901263200405.
  44. ↑ Thomas H. Murray (1983). "The Coercive Power of Drugs in Sports". Hastings Center Report 13 (4): 24–30. doi:10.2307/3561718.
  45. ↑ "Hemangeol - Food and Drug Administration" (PDF). 1 March 2014. Retrieved 23 March 2015.
  46. ↑ A.K. Sood, J.L.Watkins, P.H. Thaker (2015). "Clinical impact of selective and nonselective beta-blockers on survival in patients with ovarian cancer". Cancer: Online-first. doi:10.1002/cncr.29392.
  47. ↑ https://clinicaltrials.gov/show/NCT01504126. Retrieved 17 October 2015. Missing or empty |title= (help)

External links

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