Beta-Blocker·Psychiatry - Acute Calming & Sedation

Propranolol

Migraine prophylaxis, essential tremor, performance anxiety, thyrotoxicosis, portal hypertension

PBSBETA-BLOCKERDeralin, Inderal40 mg tabletS4+1

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At a glance

Max Dose

120 mg/day (Psych)

Half-life

3-6 h

High risk: Asthma

CONTRAIND.

Akathisia

1ST LINE

Cautions

Avoid / Cautions

Asthma, 2nd/3rd degree heart block, severe bradycardia, cardiogenic shock. Pregnancy Category C (Risk of fetal bradycardia).

Where it stands

Rapid Summary

Overview

Highly lipophilic, non-selective beta-blocker. Crosses the blood-brain barrier easily. The absolute gold-standard treatment for antipsychotic-induced akathisia and performance anxiety.

Clinical Focus

Will cause lethal bronchospasm in asthmatics due to Beta-2 blockade in the lungs.

Bottom Line

Propranolol is a non-selective beta-blocker for essential tremor, performance anxiety, and migraine prophylaxis, but is absolutely contraindicated in asthma and can mask hypoglycaemia symptoms in diabetics.

Formulation & Access

Brand Names

Deralin, Inderal

Oral Routes

Tablets (10, 40 mg).

Parenteral

Ampoules for IV use (Rare, used in thyroid storm).

Prescribing & PBS

Unrestricted General Benefit (S4).

Indications & Use

Primary

PBSTGA

Migraine prophylaxis, essential tremor, performance anxiety, thyrotoxicosis, portal hypertension.

Off-Label

OFF

Akathisia, PTSD (fear-memory extinction).

Clinical Place

The most versatile non-cardiac beta-blocker in medicine due to its CNS penetration.

Quick reference

Class & Role

Beta-Blocker — Highly lipophilic, non-selective beta-blocker.

Route / Formulation

Tablets (10, 40 mg). (Deralin, Inderal)

Usual Dose & Max

PO 10-20 mg BD to TDS. Titrate to response. Max 120 mg/day (for anxiety/akathisia). Cardiac doses are higher.

Key Indication Doses

Akathisia (Antipsychotic-induced): PO 10-20 mg BD to TDS. Titrate to response. Performance Anxiety: PO 10-40 mg STAT, taken 60 mins before the triggering event. Essential Tremor / Thyrotoxicosis: PO 40 mg BD to TDS.

Best Uses

Key Risks

Respiratory: Bronchospasm (can trigger status asthmaticus). Cardiovascular: Bradycardia, hypotension, cold extremities. Neurological: Fatigue, vivid dreams, nightmares, depression (due to high CNS penetration). Metabolic: Masks physiological signs of hypoglycemia (tremor, tachycardia) in diabetics.

Key Interactions

Non-DHP CCBs (Verapamil, Diltiazem) cause fatal heart block/asystole. Adrenaline. If a patient on Propranolol is given Adrenaline, the Beta-2 receptors are blocked, leaving Alpha-1 unopposed, causing a massive, lethal hypertensive spike.

Monitoring

Check HR and BP before initiating. Do not give if HR < 55 bpm. No specific routine laboratory tests required.

Clinical Pearl

When a patient on Aripiprazole or Haloperidol is pacing the halls relentlessly (akathisia), Propranolol 10mg BD cures the restlessness within hours without sedating the patient. It is vastly superior to Diazepam for this indication.

Access

Deralin, Inderal40 mg tablet

Brand: Deralin, Inderal
Formulation: Tablets (10, 40 mg).

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