Management of hypertension, angina pectoris, pheochromocytoma, essential tremor, tetralogy of Fallot cyanotic spells, and arrhythmias (such as atrial fibrillation and flutter, A-V nodal re-entrant tachycardias, and catecholamine-induced arrhythmias); prevention of myocardial infarction, migraine headache;

Safety and efficacy in children have not been established; administer very cautiously to patients with CHF, asthma, diabetes mellitus, hyperthyroidism. Abrupt withdrawal of the drug should be avoided, drug should be discontinued over 1-2 weeks; do not use in pregnant women; use with caution in breast-feeding women; may potentiate hypoglycemia in a diabetic patient and mask signs and symptoms.

Uncompensated congestive heart failure, cardiogenic shock, bradycardia or heart block, pulmonary edema, severe hyperactive airway disease or chronic obstructive lung disease, Raynaud’s disease, hypersensitivity to beta-blockers

>10%: Cardiovascular: Bradycardia; Central nervous system: Mental depression; Endocrine & metabolic: Decreased sexual ability.
1% to 10%: Cardiovascular: Congestive

heart failure, reduced peripheral circulation; Central nervous system: Confusion, hallucinations, dizziness Gastrointestinal: Diarrhea, nausea, vomiting, stomach discomfort; Neuromuscular & skeletal: Weakness; Respiratory: Wheezing.<1%: Chest pain, hypotension, impaired myocardial contractility, worsening of A-V conduction disturbances, nightmares, vivid dreams, lethargy, red, scaling, or crusted skin; hypoglycemia, hyperglycemia, GI distress, leukopenia, thrombocytopenia, agranulocytosis, bronchospasm, cold extremities

Decreased effect: Aluminum salts, barbiturates, calcium salts, cholestyramine, colestipol, NSAIDs, penicillins (ampicillin), rifampin, salicylates and sulfinpyrazone decrease effect of beta-blockers due to decreased bioavailability and plasma levels Beta-blockers may decrease the effect of sulfonylureas Ascorbic acid decreases propranolol Cpmax and AUC and increases the

Tmax significantly resulting in a greater decrease in the reduction of heart rate, possibly due to decreased absorption and first pass metabolism (n=5) Nefazodone decreased peak plasma levels and AUC of propranolol and increases time to reach steady state; monitoring of clinical response is recommended Increased effect: Increased effect/toxicity of beta-blockers with calcium blockers (diltiazem, felodipine, nicardipine), contraceptives, flecainide, haloperidol (hypotensive effects), H2-antagonists (cimetidine, possibly ranitidine), hydralazine, loop diuretics, possibly MAO inhibitors, phenothiazines, propafenone, quinidine (in extensive metabolizers), ciprofloxacin, thyroid hormones (metoprolol, propranolol, when hypothyroid patient is converted to euthyroid state) Beta-blockers may increase the effect/toxicity of flecainide, haloperidol (hypotensive effects), hydralazine, phenothiazines, acetaminophen, anticoagulants (warfarin), benzodiazepines, clonidine (hypertensive crisis after or during withdrawal of either agent), epinephrine (initial hypertensive episode followed by bradycardia), nifedipine and verapamil lidocaine, ergots (peripheral ischemia), prazosin (postural hypotension) Beta-blockers may affect the action or levels of ethanol, disopyramide, nondepolarizing muscle relaxants and theophylline although the effects are difficult to predict.

Symptoms of intoxication include cardiac disturbances, CNS toxicity, bronchospasm, hypoglycemia and hyperkalemia. The most common cardiac symptoms include hypotension and bradycardia; atrioventricular block, intraventricular conduction disturbances, cardiogenic shock, and asystole may occur with severe overdose,

especially with membrane-depressant drugs (eg, propranolol); CNS effects include convulsions, coma, and respiratory arrest is commonly seen with propranolol and other membrane-depressant and lipid-soluble drugs.
Treatment includes symptomatic treatment of seizures, hypotension, hyperkalemia and hypoglycemia; bradycardia and hypotension resistant to atropine, isoproterenol or pacing may respond to glucagon; wide QRS defects caused by the membrane-depressant poisoning may respond to hypertonic sodium bicarbonate; repeat-dose charcoal, hemoperfusion, or hemodialysis may be helpful in removal of only those beta-blockers with a small Vd, long half-life or low intrinsic clearance (acebutolol, atenolol, nadolol, sotalol)

Take exactly as directed; do not increase, decrease, or discontinue without consulting prescriber. Take at the same time each day. Tablets may be crushed and taken with liquids. Do not alter dietary intake of protein or carbohydrates without consulting prescriber.

You may experience orthostatic hypotension, dizziness, drowsiness, or blurred vision (use caution when driving, climbing stairs,or changing position - rising from sitting or lying to standing - or engaging in tasks requiring alertness until response to drug is known); nausea, vomiting, or stomach discomfort (small frequent meals, frequent mouth care, chewing gum, or sucking lozenges may help); decreased sexual ability (reversible). If diabetic, monitor serum glucose closely. Report unusual swelling of extremities, difficulty breathing, unresolved cough, or unusual weight gain, cold extremities, persistent diarrhea, confusion, hallucinations, headache, nervousness, lack of improvement, or worsening of condition. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to be pregnant. Consult prescriber if breast-feeding.