Propranolol is a prescription beta blocker, first sold as Inderal, that blocks both β1 receptors (mainly in the heart) and β2 receptors (in the airways, blood vessels, liver and muscle). The FDA approved it in 1967, and it is now a widely available generic. Its labeled uses span high blood pressure, angina, atrial fibrillation, survival after a heart attack, migraine prevention, essential tremor, and, as a separate oral solution, infantile hemangioma.
Outside its labeled uses, propranolol is best known as a single-dose drug for “stage fright” or performance anxiety. The trials behind that use are small and old, and two systematic reviews found no reliable benefit in diagnosed anxiety disorders. Because it steadies the hands and slows the heart, the World Anti-Doping Agency (WADA) bans it in precision sports such as archery and shooting. Stopping it suddenly can worsen angina or trigger a heart attack, and it should not be used by people with bronchial asthma.
This page summarizes what the FDA labels, clinical trials, guidelines and WADA report. It is for education only and is not medical advice.
| Property | Detail |
|---|---|
| Drug class | Non-selective beta-adrenergic blocker (β1 and β2) with no other autonomic activity |
| Brands / approval | Inderal tablets (NDA 016418, approved November 13, 1967; brand tablets now discontinued); Inderal LA (1983); InnoPran XL / Inderal XL (2003); Hemangeol oral solution (2014); many generics |
| Route | Oral tablets, extended-release capsules, oral solution; intravenous injection |
| Strengths (US) | Tablets 10, 20, 40, 60, 80 mg; Inderal LA 60, 80, 120, 160 mg; XL capsules 80, 120 mg; Hemangeol 4.28 mg/mL |
| Typical labeled adult doses | Hypertension: 40 mg twice daily to start, usually 120–240 mg/day (tablets); maximum labeled 640 mg/day |
| Half-life (labels) | 3–6 h (tablets); apparent ≈10 h (Inderal LA); ≈8 h (XL capsules) |
| Oral bioavailability | ≈25%, because of heavy first-pass metabolism in the liver |
| US status | Prescription only; no DEA schedule |
| WADA status | P1 beta-blocker: prohibited in competition in specific sports; also out of competition in archery, shooting and some underwater sports |
What it is
Propranolol hydrochloride is chemically (±)-1-(isopropylamino)-3-(1-naphthyloxy)-2-propanol hydrochloride, molecular weight 295.80 (propranolol tablets label). It is a racemic mixture of two mirror-image forms. The S(−) form is about 100 times more potent at blocking beta receptors than the R(+) form.
The label describes propranolol as competing with adrenaline-like agonists for beta-receptor sites. When those sites are blocked, the heart-rate (chronotropic), contraction-force (inotropic) and vessel-widening responses to beta stimulation fall in proportion. At doses above those needed for beta blockade, it also has a “membrane-stabilizing” (local-anesthetic-like) action on the heart, whose clinical relevance is uncertain.
Because it blocks β2 receptors as well as β1, propranolol differs from “cardioselective” drugs. The table below shows the practical consequences that the labels and trials describe.
| Receptor blocked | Main site | Consequence of blockade |
|---|---|---|
| β1 | Heart, kidney (renin release) | Slower heart rate, less forceful contraction, lower renin |
| β2 | Airways, blood vessels, liver, skeletal muscle | Can narrow the airways; blunts bronchodilator drugs; can mask or worsen low blood sugar; reduces tremor |
The related library page on nebivolol covers a β1-selective blocker with added nitric-oxide-mediated vasodilation.
Pharmacokinetics
Propranolol is highly fat-soluble and almost completely absorbed, but the liver removes most of each oral dose on first pass. Only about 25% reaches the circulation (tablets label). It crosses the blood–brain barrier and the placenta and passes into breast milk, which helps explain its central nervous system side effects.
| Parameter | Immediate-release tablets | Inderal LA capsules | XL capsules (InnoPran XL / Inderal XL) |
|---|---|---|---|
| Time to peak | 1–4 h | ≈6 h | — |
| Half-life | 3–6 h | ≈10 h (apparent) | ≈8 h |
| Exposure | Reference | AUC ≈60–65% of the same divided dose of tablets | — |
| Dosing | 2–4 times daily | Once daily | Once daily at bedtime |
Sources: tablets label; Inderal LA label; InnoPran XL label.
Other label points on how the body handles it:
- Metabolism. Three main routes: ring hydroxylation (≈42%), side-chain oxidation (≈41%) and direct glucuronidation (≈17%). The enzymes involved are CYP2D6, CYP1A2 and CYP2C19, which is why many drugs alter its levels.
- Protein binding. About 90% bound to plasma proteins; volume of distribution about 4 L/kg.
- Food. Protein-rich meals raise the bioavailability of the tablets by about 50%.
- Older adults. In one study the half-life was about 11 h in people aged 62–79, versus 5 h in people aged 25–33.
- Liver disease. In cirrhosis, unbound drug levels rose about 3-fold and half-life rose to 11 h from 4 h.
- Smoking. Cigarette smoking can increase propranolol clearance by up to 77%.
- Dialysis. Propranolol is not significantly removed by dialysis.
Approved medical use
The labeled indications differ by product. The immediate-release tablets carry the widest set (tablets label):
| Indication | Labeled adult dosing (tablets) |
|---|---|
| Hypertension | 40 mg twice daily to start; usual 120–240 mg/day; up to 640 mg/day in some cases |
| Angina due to coronary atherosclerosis | 80–320 mg/day in 2–4 doses |
| Atrial fibrillation (ventricular rate control) | 10–30 mg three or four times daily |
| After myocardial infarction (to reduce cardiovascular death) | 180–240 mg/day in divided doses |
| Migraine prophylaxis (not acute attacks) | 80 mg/day to start; usual 160–240 mg/day |
| Familial or hereditary essential tremor | 40 mg twice daily to start; optimum usually 120 mg/day; occasionally 240–320 mg/day |
| Hypertrophic subaortic stenosis | 20–40 mg three or four times daily |
| Pheochromocytoma (only with alpha blockade) | 60 mg/day for 3 days before surgery; 30 mg/day for inoperable tumors |
Other products have narrower labels:
- Inderal LA (once-daily capsules): hypertension, angina, migraine prophylaxis and hypertrophic subaortic stenosis (Inderal LA label).
- InnoPran XL / Inderal XL (bedtime capsules): hypertension only, starting at 80 mg and titrating to 120 mg; the label states doses above 120 mg had no additional blood-pressure effect (InnoPran XL label).
- Hemangeol (oral solution): proliferating infantile hemangioma that needs systemic therapy, started at 5 weeks to 5 months of age and titrated over two weeks to 1.7 mg/kg twice daily for 6 months (Hemangeol label).
- Intravenous injection: short-term control of supraventricular tachycardias and certain other arrhythmias, including those of digitalis toxicity and of excess catecholamines during anesthesia (propranolol injection label).
Performance anxiety, social anxiety and other anxiety disorders are not labeled indications for any US propranolol product.
What the research shows
After a heart attack
The tablets label summarizes the Beta-Blocker Heart Attack Trial (BHAT): a randomized, double-blind, placebo-controlled trial in 3,837 people who had survived the acute phase of a heart attack. Propranolol (60 or 80 mg three times daily), started 5–21 days after the infarction, reduced total mortality by 39% at 12 months and by 26% over an average follow-up of 25 months, mainly through fewer cardiovascular deaths (tablets label).
Migraine prevention
The American Academy of Neurology and American Headache Society guideline classed propranolol, with metoprolol, timolol, topiramate and divalproex, as Level A: established as effective and to be offered to reduce migraine frequency and severity (Silberstein et al., Neurology 2012). The label stresses that it prevents attacks but does not treat one already under way.
Essential tremor
The American Academy of Neurology guideline rates propranolol and primidone as Level A, established as effective for limb tremor in essential tremor (Zesiewicz et al., Neurology 2011). The label adds that propranolol reduces tremor amplitude but not frequency, and is not indicated for tremor in Parkinsonism.
Infantile hemangioma
In a randomized, double-blind phase 2–3 trial, 456 infants aged 1–5 months received placebo or one of four propranolol regimens (Léauté-Labrèze et al., NEJM 2015). The selected regimen, 3 mg/kg/day for 6 months, led to complete or nearly complete resolution at week 24 in 60% vs 4% with placebo. About 10% of successfully treated infants later needed systemic retreatment. The Hemangeol label describes the same 460-infant study.
Performance anxiety (off-label)
Performance anxiety (“stage fright”) is the best-known off-label use. The idea is to blunt the physical symptoms driven by adrenaline, such as a racing heart, shaking hands and a trembling voice. The evidence comes mainly from small, single-dose studies from the 1970s to early 1990s:
| Study | Design and n | Dose | Main finding |
|---|---|---|---|
| Brantigan et al., Am J Med 1982 | Two double-blind trials, 29 musicians | Propranolol vs placebo (dose not stated in the abstract); terbutaline also tested | Physical stage-fright symptoms reduced; performance quality rated better by music critics; the beta stimulant terbutaline made stage fright worse |
| Hartley et al., Br J Psychiatry 1983 | Placebo-controlled; anxious and non-anxious volunteers giving a videotaped speech | 40 mg single dose | Less observer-rated and self-reported anxiety in anxious speakers; lower pulse in all; worse recall of difficult words in anxious subjects |
| Faigel, Clin Pediatr 1991 | Uncontrolled before–after study, 32 high-school students with test anxiety | 40 mg one hour before retaking the SAT | Mean score 130 points higher than the earlier unmedicated attempt; no placebo group, so practice effects cannot be separated out |
A systematic review of performance anxiety in professional musicians found 43 studies, with prevalence estimates of 16.5–60% (Fernholz et al., Psychol Med 2019). Cognitive behavioral therapy (CBT) and beta blockers were the most-studied treatments, with beneficial results reported for CBT. The authors noted widespread weaknesses in randomization, blinding and control groups. In one clinical sample, 10 of 15 full-time professional musicians had already tried propranolol (Clark and Agras, Am J Psychiatry 1991).
Anxiety disorders
For diagnosed anxiety disorders, two systematic reviews reached similar conclusions:
- A 2016 meta-analysis of 8 randomized trials of propranolol found no significant difference from benzodiazepines for short-term treatment of panic disorder. It found no evidence of an effect on PTSD symptom severity, and judged the evidence insufficient to support routine use for any anxiety disorder (Steenen et al., J Psychopharmacol 2016). Only one included trial studied social phobia (n = 16).
- A 2025 review of all beta blockers included 10 studies, 5 of them in meta-analyses (n = 179). It found no evidence of benefit versus placebo or benzodiazepines in social phobia or panic disorder (all p ≥ 0.54). The authors noted that beta-blocker prescriptions for anxiety increased substantially between 2003 and 2018 despite this (Archer et al., J Affect Disord 2025).
Both reviews flagged small samples and high or unclear risk of bias. The honest summary is that propranolol reliably lowers heart rate and tremor, while its effect on anxiety itself, and on performance quality, rests on weak evidence.
Exercise and sport performance
Beta blockade cuts the heart-rate and fat-burning (lipolysis) responses that endurance exercise relies on. A review found that beta blockers reduce maximal aerobic capacity in people with normal blood pressure, and impair submaximal endurance much more. That impairment was more pronounced with non-selective drugs such as propranolol than with β1-selective ones (Van Baak, Sports Med 1988).
In a double-blind crossover study, 12 healthy volunteers took placebo, atenolol or propranolol for 14 days each and cycled to exhaustion at 70% of maximal aerobic power (van Baak et al., Int J Sports Med 1993):
| Treatment | Change in endurance time vs placebo |
|---|---|
| Atenolol (β1-selective) | −11% (not significant) |
| Propranolol (non-selective) | −40% (p under 0.01) |
The picture is different in precision sports, where steady hands matter more than cardiac output. In 33 pistol marksmen, the β1-selective blocker metoprolol improved scores by 13.4% of the possible improvement versus placebo, an effect the authors attributed to reduced hand tremor (Kruse et al., J Appl Physiol 1986). That study did not test propranolol, but it illustrates why WADA lists the whole class for these sports.
Muscle catabolism after severe burns
Severe burns trigger an adrenaline-driven hypermetabolic state that breaks down muscle. In a randomized trial of 25 children with burns over 40% of body surface, propranolol titrated to lower resting heart rate by 20% was compared with no treatment for at least two weeks (Herndon et al., NEJM 2001):
| Outcome | Propranolol (n = 13) | Control (n = 12) |
|---|---|---|
| Net muscle-protein balance vs baseline | +82% (p = 0.002) | −27% (not significant) |
| Fat-free mass during hospitalization | No substantial change | −9 ± 2% (p = 0.003) |
This is an anti-catabolic effect in a specific critical-care setting. It does not show that propranolol builds muscle in healthy people, and no trial has tested that.
Side effects and risks
Abrupt discontinuation (the key warning)
The adult propranolol labels, including the injection, warn that stopping the drug suddenly has been followed by worsening angina and, in some cases, heart attack. The immediate-release and LA labels print this in bold at the top of the Warnings section rather than as a formal boxed warning. They advise tapering over at least a few weeks (tablets label; Inderal LA label). The newer XL labels advise a gradual reduction over 1–2 weeks with monitoring (InnoPran XL label).
The labels apply this warning to everyone, not only to heart patients. Coronary disease can be present without symptoms, so the XL label says to avoid abrupt stopping even when the drug is taken only for blood pressure. Sudden withdrawal can also unmask an overactive thyroid and, in rare cases, precipitate thyroid storm.
Asthma and other airway disease
Bronchial asthma is a labeled contraindication. Blocking β2 receptors in the airways can provoke bronchospasm and blunt the effect of rescue inhalers. A meta-analysis of randomized, placebo-controlled trials in people with asthma quantified the effect of a single exposure (Morales et al., Chest 2014):
| Measure | Selective β1 blockers | Non-selective blockers |
|---|---|---|
| Mean change in FEV1 (air forced out in 1 second) | −6.9% (95% CI −8.5 to −5.2) | −10.2% (95% CI −14.7 to −5.6) |
| FEV1 fall of 20% or more | 1 in 8 patients | 1 in 9 patients |
| Attenuation of β2-agonist (rescue inhaler) response | −10.2% (95% CI −14.0 to −6.4) | −20.0% (95% CI −29.4 to −10.7) |
The labels also advise that people with non-allergic bronchospastic disease, such as chronic bronchitis or emphysema, generally should not receive beta blockers.
Contraindications
The tablets and LA labels list four contraindications:
- cardiogenic shock;
- sinus bradycardia and heart block greater than first degree;
- bronchial asthma;
- known hypersensitivity to propranolol.
The XL labels add decompensated heart failure and sick sinus syndrome (unless a permanent pacemaker is in place).
Heart, blood sugar and other warnings
- Heart failure and slow heart rate. Beta blockade can precipitate or worsen heart failure. Bradycardia, sinus pause, heart block and cardiac arrest have been reported. People with Wolff-Parkinson-White syndrome may develop severe bradycardia.
- Low blood sugar. Propranolol can mask warning signs of hypoglycemia, such as a fast pulse, and can increase the risk of severe or prolonged hypoglycemia. The tablets label notes reports after prolonged physical exertion, in fasting children, and in kidney impairment.
- Anaphylaxis. People with severe allergies may react more strongly and may not respond to usual doses of epinephrine.
- Surgery. Long-term therapy should not routinely be stopped before major surgery.
- Thyroid. It can mask signs of hyperthyroidism and alter thyroid test results (higher T4 and reverse T3, lower T3).
- Eye pressure. It lowers intraocular pressure and may interfere with glaucoma screening.
Common and other adverse effects
In the placebo-controlled InnoPran XL hypertension trials, the most common adverse reactions were (InnoPran XL label):
| Adverse reaction | Placebo (n = 88) | 80 mg (n = 89) | 120 mg (n = 85) |
|---|---|---|---|
| Fatigue | 3% | 5% | 7% |
| Dizziness (except vertigo) | 2% | 7% | 4% |
| Constipation | 0% | 3% | 1% |
Across formulations, the labels also list:
- Nervous system: light-headedness, depression, insomnia, fatigue, vivid dreams, hallucinations, short-term memory loss. For immediate-release forms, fatigue, lethargy and vivid dreams appear dose-related.
- Circulation: Raynaud-type arterial insufficiency, low blood pressure, slow heart rate.
- Sexual function: male impotence; Peyronie’s disease.
- Rare serious reactions: agranulocytosis, Stevens-Johnson syndrome, toxic epidermal necrolysis, lupus-like reactions.
Pregnancy and children
Propranolol crosses the placenta. The tablets label reports intrauterine growth restriction, small placentas and congenital abnormalities in exposed newborns, and bradycardia, hypoglycemia and respiratory depression in newborns exposed at delivery. The label states that safety and effectiveness of the adult products in children have not been established. Hemangeol is the only product labeled for infants.
Interactions
Propranolol is metabolized by CYP2D6, CYP1A2 and CYP2C19, and it adds to the effects of other drugs that slow the heart. Key interactions from the labels:
| Drug or factor | Effect |
|---|---|
| Verapamil, diltiazem | Bradycardia, heart block, heart failure and cardiovascular collapse reported |
| Digoxin, amiodarone | Additive slowing of heart rate and conduction |
| Clonidine | Rebound hypertension if clonidine is stopped abruptly; the XL label advises withdrawing the beta blocker several days first |
| Quinidine | Propranolol levels rise 2–3-fold |
| CYP2D6 inhibitors (fluoxetine, paroxetine, bupropion) | Higher propranolol exposure |
| CYP1A2 / CYP2C19 inhibitors (ciprofloxacin, fluvoxamine, fluconazole, cimetidine) | Higher exposure; cimetidine raised AUC by 46% |
| Inducers (rifampin, phenytoin, smoking) | Lower propranolol levels |
| Cholestyramine, colestipol | Up to 50% lower propranolol levels |
| Epinephrine | Severe hypertension from unopposed alpha stimulation; poor response when used for anaphylaxis |
| Beta agonists (e.g. albuterol, clenbuterol, isoproterenol, dobutamine) | Competitive opposition at beta receptors; propranolol blocks the bronchodilation produced by beta stimulants |
| Warfarin | Higher warfarin levels; monitor prothrombin time |
| Rizatriptan, zolmitriptan | Triptan AUC up 67% and 56%, respectively |
| Thioridazine | Thioridazine levels up 55–369% with propranolol at 160 mg/day or more |
| Theophylline | Theophylline clearance down 30–52% |
| Lidocaine | Lidocaine levels up ≈25%; toxicity reported |
| NSAIDs (e.g. indomethacin) | Weaker blood-pressure-lowering effect |
| Alcohol | May raise propranolol levels |
Sources: tablets label; InnoPran XL label.
The beta-2 agonist interaction matters on this site because albuterol and clenbuterol work through the same β2 receptors that propranolol blocks. In the asthma meta-analysis above, non-selective blockers cut the response to a β2-agonist by about 20%.
Legal status and anti-doping
In the US, propranolol is a prescription drug with no DEA schedule. Brand Inderal tablets are listed as discontinued, and FDA has recorded that they were not withdrawn for safety or effectiveness reasons (Drugs@FDA, NDA 016418). Generic tablets and other propranolol products remain available.
The WADA 2026 Prohibited List names propranolol under P1 Beta-blockers, as a Specified Substance. Beta blockers are banned in competition only in the listed sports, and also out of competition where marked:
| Sport (federation) | In competition | Out of competition |
|---|---|---|
| Archery (WA) | Prohibited | Prohibited |
| Shooting (ISSF, IPC) | Prohibited | Prohibited |
| Underwater sports (CMAS): freediving, spearfishing, target shooting | Prohibited | Prohibited |
| Automobile (FIA) | Prohibited | — |
| Billiards, all disciplines (WCBS) | Prohibited | — |
| Darts (WDF) | Prohibited | — |
| Golf (IGF) | Prohibited | — |
| Mini-golf (WMF) | Prohibited | — |
Beta blockers are not on the WADA list for other sports. The same P1 entry covers metoprolol, nebivolol, atenolol and other members of the class.
Key takeaways
- A broad-label, non-selective beta blocker. Propranolol blocks both β1 and β2 receptors and is FDA-labeled for hypertension, angina, atrial fibrillation, post-heart-attack care, migraine prevention, essential tremor and, as Hemangeol, infantile hemangioma.
- Do not stop it suddenly. The adult labels warn that abrupt withdrawal has been followed by worse angina and heart attacks, and advises a gradual taper.
- Asthma is a contraindication. Non-selective blockade can cause bronchospasm and cut the response to rescue inhalers by about 20%.
- Performance anxiety is off-label with thin evidence. Small single-dose studies show fewer physical symptoms, but reviews find no reliable benefit in anxiety disorders.
- Bad for endurance, banned for precision. Propranolol cut endurance time by 40% in one trial, while WADA prohibits beta blockers in archery, shooting, golf and other precision sports.
Sources
- Mylan Pharmaceuticals. Propranolol hydrochloride tablets, USP, prescribing information. DailyMed.
- ANI Pharmaceuticals. Inderal LA (propranolol hydrochloride) extended-release capsules, prescribing information. DailyMed.
- ANI Pharmaceuticals. InnoPran XL (propranolol hydrochloride) extended-release capsules, prescribing information. DailyMed.
- Pierre Fabre Pharmaceuticals. Hemangeol (propranolol hydrochloride) oral solution, prescribing information. DailyMed.
- Hikma Pharmaceuticals. Propranolol hydrochloride injection, prescribing information. DailyMed.
- US Food and Drug Administration. Drugs@FDA: Inderal, NDA 016418; Inderal LA, NDA 018553; Hemangeol, NDA 205410. FDA.
- World Anti-Doping Agency. The 2026 Prohibited List: International Standard. WADA 2026 Prohibited List.
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