Propranolol

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Propranolol on Prescriptsy

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Propranolol is a non-selective beta-adrenergic receptor antagonist (beta-blocker) that has been a cornerstone of cardiovascular and neurological therapeutics since its development by Sir James Black in the 1960s, for which he was awarded the Nobel Prize in Physiology or Medicine in 1988.

In the United Kingdom, propranolol is licensed for hypertension, angina pectoris, cardiac arrhythmias, essential tremor, migraine prophylaxis, anxiety-related tachycardia, thyrotoxicosis, phaeochromocytoma (adjunctive), and hypertrophic obstructive cardiomyopathy.

It is one of the most widely prescribed beta-blockers in UK general practice, available as immediate-release tablets (10 mg, 40 mg, 80 mg, 160 mg), modified-release capsules (80 mg, 160 mg), and oral solution.

This page provides a comprehensive clinical overview of propranolol, including its pharmacology, indications, dosing guidance, side effects, contraindications, and how to obtain a prescription in the UK.

It is written for patients who have been prescribed propranolol or who wish to understand how this medication works.

Important safety information about propranolol

Before reading further, note the following key safety points about propranolol.

• Do not take propranolol if you have asthma. Non-selective beta-blockers can cause severe bronchospasm in people with asthma.
• Do not stop propranolol suddenly. Abrupt withdrawal may cause rebound tachycardia, hypertension, or worsening angina. Dose reduction must be gradual.
• If you have diabetes, propranolol may mask some warning signs of low blood sugar. Monitor your glucose levels closely.
• Tell your prescriber about all other medications, particularly calcium channel blockers, anti-arrhythmics, and diabetes treatments.

What are beta-blockers

Beta-blockers are a class of medications that block the effects of adrenaline (epinephrine) and noradrenaline (norepinephrine) at beta-adrenergic receptors.

There are three main types of beta receptor: beta-1 receptors are found predominantly in the heart and kidneys; beta-2 receptors are found in the lungs, blood vessels, liver, and skeletal muscle; beta-3 receptors are found in adipose tissue.

Propranolol is non-selective, meaning it blocks both beta-1 and beta-2 receptors.

This distinguishes it from cardioselective beta-blockers such as bisoprolol and atenolol, which preferentially block beta-1 receptors and carry a lower risk of bronchospasm.

How propranolol works: mechanism of action

Propranolol exerts its therapeutic effects through several interconnected mechanisms.

By blocking beta-1 receptors in the sinoatrial node and myocardium, it reduces heart rate, slows atrioventricular conduction, and decreases myocardial contractility.

This lowers cardiac output and myocardial oxygen demand, which is the basis of its efficacy in angina and hypertension.

By blocking beta-1 receptors in the juxtaglomerular cells of the kidney, it suppresses renin secretion and thereby reduces angiotensin II and aldosterone production, contributing to its antihypertensive effect.

Propranolol is highly lipophilic and crosses the blood-brain barrier more readily than hydrophilic beta-blockers (such as atenolol).

This central nervous system penetration underlies its efficacy in migraine prophylaxis, essential tremor, and the management of physical symptoms of anxiety.

In the CNS, propranolol modulates noradrenergic neurotransmission and is thought to reduce central sympathetic outflow.

The membrane-stabilising (local anaesthetic) effect of propranolol occurs at concentrations higher than those typically achieved at therapeutic doses, and its clinical significance at standard doses is uncertain.

Propranolol undergoes extensive first-pass hepatic metabolism via cytochrome P450 enzymes CYP2D6 and CYP1A2, resulting in an oral bioavailability of approximately 25 to 35%.

The elimination half-life is 3 to 6 hours for immediate-release formulations. Modified-release preparations provide a more sustained plasma profile and allow once-daily dosing.

Indications and clinical evidence

Hypertension

Propranolol lowers blood pressure by reducing cardiac output and suppressing renin release.

While beta-blockers were previously considered first-line antihypertensives, NICE Guideline NG136 now recommends them as fourth-line agents, after ACE inhibitors or ARBs, calcium channel blockers, and thiazide-like diuretics.

Beta-blockers remain appropriate first-line options in younger patients with sympathetic overactivity, women of childbearing potential (where ACE inhibitors are contraindicated), and patients with co-existing conditions such as angina, migraine, or essential tremor.

Angina pectoris

By reducing heart rate and myocardial contractility, propranolol decreases myocardial oxygen demand during exertion, reducing the frequency and severity of angina episodes.

It is recommended alongside or as an alternative to calcium channel blockers for the prevention of stable angina symptoms.

Migraine prophylaxis

Propranolol is the most extensively studied beta-blocker for migraine prevention and is recommended by NICE CKS as a first-line prophylactic option.

It is thought to work via central noradrenergic modulation, vascular tone stabilisation, and reduction of cortical excitability.

Clinical trials have demonstrated a 40 to 50% reduction in migraine frequency in responsive patients.

Essential tremor

Propranolol is the most effective pharmacological treatment for essential tremor and is recommended as first-line therapy.

It reduces the amplitude and, to a lesser extent, the frequency of postural and kinetic tremor.

The mechanism involves blockade of peripheral beta-2 receptors in skeletal muscle spindles and central beta-adrenergic modulation.

Anxiety

Propranolol is widely used for the short-term management of physical symptoms of anxiety, including palpitations, tremor, sweating, and gastrointestinal disturbance.

It is particularly effective for situational or performance anxiety, where a single dose taken 30 to 60 minutes before the event can significantly reduce physical symptoms without causing sedation or cognitive impairment.

It does not treat the psychological component of anxiety and is not a substitute for psychological therapy or anxiolytic medication in generalised anxiety disorder.

Thyrotoxicosis

Propranolol provides rapid symptomatic relief of the adrenergic manifestations of thyrotoxicosis, including tachycardia, tremor, sweating, and anxiety.

It is used as adjunctive treatment alongside anti-thyroid drugs (carbimazole or propylthiouracil) while awaiting biochemical control.

Propranolol also inhibits the peripheral conversion of thyroxine (T4) to triiodothyronine (T3), providing a modest additional thyroid-modulating effect.

Dosage and administration

The dose of propranolol varies widely depending on the indication.

For hypertension, the usual maintenance dose is 160 to 320 mg daily in divided doses or as a single daily dose using modified-release capsules.

For migraine prophylaxis, 80 to 160 mg daily is typical. For essential tremor, 40 to 160 mg daily.

For situational anxiety, a single dose of 10 to 40 mg is taken 30 to 60 minutes before the event.

Propranolol should be taken with or after food to increase bioavailability by reducing first-pass metabolism.

Modified-release capsules (such as Half Inderal LA and Inderal LA) should be swallowed whole and not chewed or crushed.

Treatment should always be started at a low dose and titrated upward according to response and tolerability, with regular monitoring of heart rate and blood pressure.

Do not stop propranolol abruptly.

If discontinuation is necessary, reduce the dose gradually over 1 to 2 weeks under medical supervision to avoid rebound tachycardia, hypertension, and worsening angina.

Patients with ischaemic heart disease are at particular risk from abrupt withdrawal.

Side effects of propranolol

Common side effects

The most frequently reported side effects of propranolol include fatigue, lethargy, cold extremities, dizziness, and sleep disturbance (including vivid dreams, nightmares, and insomnia).

Cold hands and feet result from beta-2 blockade-mediated peripheral vasoconstriction. These effects are generally mild and may improve after the first few weeks of treatment.

Cardiovascular effects

Bradycardia is an expected pharmacological effect but may become symptomatic (dizziness, lightheadedness, syncope) if the heart rate falls excessively.

Hypotension may occur, particularly in the initial dose titration period. Worsening of heart failure symptoms is possible in patients with borderline cardiac compensation.

Heart block (second or third degree) is rare at therapeutic doses but may occur with concomitant use of rate-limiting calcium channel blockers.

Respiratory effects

Bronchospasm is a serious risk in patients with asthma or reactive airway disease. Even in patients without known airway disease, wheeze or breathlessness may occasionally occur. Propranolol should be stopped immediately if bronchospasm develops.

Metabolic effects

In patients with diabetes, propranolol may mask the adrenergic warning signs of hypoglycaemia (tremor, tachycardia, hunger) while leaving sweating unaffected. It may also prolong hypoglycaemic episodes by inhibiting glycogenolysis. Close glucose monitoring is essential.

When to seek medical advice

Contact your GP or NHS 111 if you experience persistent fatigue, dizziness, unusually slow pulse (below 50 beats per minute at rest), worsening cold extremities, mood changes, or new onset of breathlessness.

Call 999 or attend A&E if you experience severe chest pain, fainting, very slow or irregular heartbeat, severe wheeze, or difficulty breathing.

Report any suspected adverse reactions via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Warnings and precautions

Absolute contraindications

Do not take propranolol if you have asthma or a history of bronchospasm, uncontrolled heart failure, cardiogenic shock, severe bradycardia, second- or third-degree heart block, sick sinus syndrome, untreated phaeochromocytoma, metabolic acidosis, severe peripheral arterial disease, Prinzmetal angina, or known hypersensitivity to propranolol.

Cautions

Use propranolol with caution in diabetes mellitus, hepatic impairment, renal impairment, myasthenia gravis, peripheral vascular disease, Raynaud's phenomenon, first-degree heart block, and in patients undergoing general anaesthesia. Inform your anaesthetist that you take propranolol before any surgical procedure.

Drug interactions

Propranolol interacts with many medications. Concurrent use with verapamil or diltiazem may cause severe bradycardia and heart block.

Combination with clonidine carries a risk of rebound hypertension if clonidine is withdrawn while propranolol continues. NSAIDs (such as ibuprofen) may reduce the antihypertensive effect.

Ergotamine may cause peripheral vasoconstriction. Cimetidine inhibits propranolol metabolism, increasing its plasma levels. Rifampicin induces propranolol metabolism, reducing its effect.

Always tell your prescriber about all medications and supplements you take.

Pregnancy and breastfeeding

Propranolol should be used during pregnancy only when the expected benefit outweighs the potential risk. It crosses the placenta and may cause neonatal bradycardia, hypoglycaemia, and respiratory depression.

Propranolol is excreted in breast milk in small amounts. Breastfeeding is generally considered acceptable at therapeutic doses, but the infant should be monitored for signs of beta-blockade.

How to get a propranolol prescription in the UK

Propranolol is a prescription-only medicine (POM) in the UK.

It can be prescribed by your GP, a hospital specialist, or an authorised online prescriber registered with the GPhC following clinical assessment.

Your prescriber will assess your medical history, current medications, blood pressure, and heart rate before initiating treatment.

Generic propranolol tablets are widely available and are the most commonly prescribed formulation.

The standard NHS prescription charge in England is currently 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

When to seek urgent medical advice

Seek immediate medical attention if you experience severe chest pain, fainting or loss of consciousness, very slow or irregular heartbeat, severe difficulty breathing or wheezing, or signs of a severe allergic reaction (facial swelling, throat tightness, widespread rash).

Call 999 or attend A&E for any of these symptoms.

Contact your GP or NHS 111 for non-urgent concerns such as persistent side effects, worsening cold extremities, or mood changes.

Report any suspected adverse reactions via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Sources

• Propranolol hydrochloride 40 mg tablets, Summary of Product Characteristics (EMC)
• Propranolol hydrochloride, British National Formulary (BNF)
• NICE CKS: Hypertension
• NICE NG136: Hypertension in adults
• Propranolol, NHS
• MHRA Yellow Card Scheme