Other Warnings/Precautions

• May elevate blood urea, serum transaminases, alkaline phosphatase, and LDH

• Rare development of antinuclear antibodies (ANAs)

• May worsen symptoms of myasthenia gravis

• Can lower intraocular pressure, interfering with glaucoma screening test

Do Not Use

• If patient has bradycardia, greater than first-degree heart block, or cardiogenic shock

• If patient has bronchial asthma or severe COPD

• If there is a proven allergy to propranolol

PROPRANOLOL: SPECIAL POPULATIONS

Renal Impairment

• No dose adjustment necessary

Hepatic Impairment

• Use with caution with severe impairment; dose reduction may be necessary

Cardiac Impairment

• Do not use in acute shock, myocardial infarction, hypotension, and greater than first-degree heart block, but indicated in clinically stable patients post–myocardial infarction to reduce risk of re-infarction starting 1–4 weeks after event

Elderly

• Use with caution

• May increase risk of stroke

Children and Adolescents

• Usual dose in children is 2–4 mg/kg in 2 divided doses; maximum 16 mg/kg/day

• Clinical trials for migraine prophylaxis did not include children

Pregnancy

• Risk Category C [some animal studies show adverse effects; no controlled studies in humans]

• May reduce perfusion of the placenta

• Use only if potential benefits outweigh the potential risks to the fetus

Breast Feeding

• Some drug is found in mother’s breast milk

• Due to high lipid solubility, propranolol is found in breast milk more than many other beta blockers

✽ Recommended either to discontinue drug or bottle feed unless the potential benefit to the mother justifies the potential risk to the child

PROPRANOLOL: THE ART OF PSYCHOPHARMACOLOGY

Potential Advantages

• Patients who do not respond to or tolerate other options

• Patients with autonomic hyperactivity

Potential Disadvantages

• Multiple potential undesirable AEs, including bradycardia, hypotension, and fatigue

Primary Target Symptoms

• Migraine frequency and severity

• Tremor

• Effects of stress from prior traumatic experience

• Aggression, agitation

Pearls

• Often used in combination with other drugs in migraine, which may allow patients to better tolerate medications that cause tremor, such as valproate

• May worsen depression, but helpful for anxiety

• 50–70% of patients with essential tremor receive some relief, usually with about 50% improvement or greater

• Propranolol may theoretically block the effects of stress from prior traumatic experiences, but this is unproven and data thus far are mixed

Suggested Reading

Brunet A, Poundja J, Tremblay J, et al. Trauma reactivation under the influence of propranolol decreases posttraumatic stress symptoms and disorders: 3 open-label trials. J Clin Psychopharmacol 2011;31(4):547–50.

Cohen H, Kaplan Z, Koresh O, et al. Early post-stressor intervention with propranolol is ineffective in preventing posttraumatic stress responses in an animal model for PTSD. Eur Neuropsychopharmacol 2011;21(3):230–40.

Fleminger S, Greenwood RJ, Oliver DL. Pharmacological management for agitation and aggression in people with acquired brain injury. Cochrane Database Syst Rev 2003;(1):CD003299.

Lyons KE, Pahwa R. Pharmacotherapy of essential tremor: an overview of existing and upcoming agents. CNS Drugs 2008;22(12):1037–45.

Silberstein SD. Preventive migraine treatment. Neurol Clin 2009;27(2):429–43.

PROTRIPTYLINE

PROTRIPTYLINE: THERAPEUTICS

Brands

• Triptil

• Vivactil

see index for additional brand names

Generic?

Yes

Class

• Tricyclic antidepressant (TCA)

• Predominantly a norepinephrine/noradrenaline reuptake inhibitor

Commonly Prescribed for

(bold for FDA approved)

• Mental depression

• Treatment-resistant depression

How the Drug Works

• Boosts neurotransmitter norepinephrine/noradrenaline

• Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably increasing noradrenergic neurotransmission

• Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which largely lacks dopamine transporters, protriptyline can increase dopamine neurotransmission in this part of the brain

• A more potent inhibitor of norepinephrine reuptake pump than serotonin reuptake pump (serotonin transporter)

• At high doses may also boost neurotransmitter serotonin and presumably increase serotonergic neurotransmission