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Drug dosage identifier

Propranolol Hydrochloride

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Dose and administration

Intravenous

20 - 100 mcg/kg by slow IV infusion over 10 minutes every 6 hours4

Oral

  • 20 -100 mcg/kg/dose 6 hourly4
  • Dosage needs to be individualised and will vary depending on both clinical diagnosis and individual patient metabolism.

Indications

  1. Hypoxic spells in Tetralogy of Fallot.
  2. Treatment of neonatal thyrotoxicosis.
  3. Tachyarrhythmia.

Precautions

  1. Use cautiously if there is heart failure.
  2. Use cautiously in heart block.
  3. Use cautiously in renal or hepatic impairment.
  4. Infants with a tendency to bronchospasm.
  5. Bradycardia, hypotension, metabolic acidosis, cardiogenic shock

Drug interactions

Caffeine An increase in propranolol dose may be required. No clear evidence for this
Chlorpromazine Possible hypotension. (Both drugs inhibit hepatic metabolism of each other)
Digoxin  May lead to bradycardia
Insulin Potential for severe, prolonged hypoglycaemia (reported in adult diabetics ).
Phenobarbitone May require increase in propranolol dose. (Increase in metabolism and clearance may occur)
Rifampicin May require increase in propranolol dose. (Increase in hepatic metabolism)
Theophylline  Increase in theophylline levels possible
Thyroid hormones Altered levels of triodothyronine, T3 and thyroxine may occur - monitor.
Flecainide Possible additive negative inotropic effect. Cardiac depression may occur
Verapamil Contraindicated in combination with a beta-blocker (negative inotropic effect)

Clinical pharmacology

Propranolol is a non-selective beta-blocker acting on both β1 (mainly heart) and β2 (bronchial tissue) receptors. Blockade of β2 receptors may result in bronchospasm in some patients. Propranolol has membrane stabilising properties in high doses. It does not have intrinsic sympathomimetic activity (ISA). It exhibits a negative inotropic effect.

Propranolol is almost completely absorbed from the GI tract (adults) and there is significant first pass metabolism and hepatic tissue binding with up to 90% of an oral dose being eliminated. At least one metabolite shows biological activity but the effect on overall activity is unknown. Metabolites and a small amount of unchanged propranolol are excreted in the urine. Propranolol is highly protein-bound (80-95%). It is widely distributed throughout the body with highest levels occurring in the lungs, kidney, brain and heart.

Possible adverse effects

  1. Bradycardia.
  2. Hypoglycaemia / hyperglycaemia.
  3. Hypotension in patients with underlying myocardial dysfunction, precipitation of heart failure or heart block
  4. Gastrointestinal effects (diarrhoea, vomiting, constipation)
  5. Thrombocytopenia.
  6. Bronchospasm.

Special considerations

  1. Monitor: - Blood glucose; Renal, hepatic and haematological studies with prolonged administration.
  2. Have atropine on hand for excessive bradycardia.
  3. Have aminophylline on hand for bronchospasm.
  4. May mask the signs of thyrotoxicosis
  5. Sudden cessation can cause withdrawal (nervousness, tachycardia, sweating, hypertension).

Management of Propranolol administration

Description

IV preparation:  Clear colourless solution 1mg/ml in 1ml ampoules.

Oral preparation: No proprietary preparation available. Refer to pharmacist.

Prescription

  • Individual doses are charted on stat page of prescription chart in mcg/dose.
  • Maintenance doses are charted on the prescription chart in mcg/dose.

Administration

Slow IV Infusion

  1. Compatible with sodium chloride 0.9%, glucose 5%. Do not mix with other IV solutions or drugs.
  2. Dilution not necessary. May be diluted for ease of administration.
  3. Flush line with sodium chloride 0.9% before and after infusion of propranolol.
  4. Filter prior to administration through a 0.22 micron filter.
  5. Administer by slow IV infusion over 10 minutes using a syringe pump.

Oral

Preferably given before food. However if there is a necessity to give with food, continue with this method consistently.

Observation and Documentation

  1. Assess for signs of adverse reaction, including hypoglycaemia
  2. Cardiorespiratory monitoring during acute usage. Report and record changes in heart rate and rhythm.
  3. Document vital signs.
  4. Document baby's response to medication

Storage

IV preparation:  Unopened. Store at room temperature <30°C. Protect from light.

Selected references

  1. Lilley B, Nolan T, Tibbalis J. Paediatric Pharmacopeaia 10th ed. The Royal Children Hospital Melbourne, July 1989 p129.
  2. Clark WG, Brater DC, Johnson AR. Goth's Medical Pharmacology. The CV Mosby Company 12th ed. 1988 p166.
  3. Pawlak RP, Herfert LAT. Drug administration in the NICU Neonatal Network 2nd ed. p228-229.
  4. Young TE, Mangum OB. Neofax 10th ed. Acorn Publishing; 1997: Raleigh, North Carolina.
  5. Yeh TF (ed). Drug therapy in the neonate and small infant. Year Book Medical Publishers Chicago 1985 p112
  6. Reynolds JEF Editor Martindale: The Extra Pharmacopoeia. (31st ed). Royal Pharmaceutical Society; 1996: London
  7. Stockley I. Drug Interactions 4th ed. The Pharmaceutical Press; 1996: London
  8. Heel R (Editor) New Ethicals Compendium (6th ed). Adis International Limited;1997: Auckland

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Document Control

  • Date last published: 30 November 1999
  • Document type: Drug Dosage Guideline
  • Services responsible: ADHB Pharmacy, Neonatology, Paediatric Cardiology
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years