Antihypertensive Pregnancy: Propranolol should not be given during pregnancy unless its use is essential. There is no evidence of teratogenicity, but beta-blockers reduce placental perfusion, which may result in intra-uterine foetal death and immature or premature deliveries; foetal bradycardia and neonatal hypoglycaemia and bradycardia may occur, with an increased risk of cardiac and pulmonary complications in the neonate post-natally. Breast-feeding is not recommended following administration.

Propranolol (Portal Hypertension)

Brand names: Inderal, Angilol

Used in: Headache & Migraine

This page covers the non-selective beta-blocker propranolol used in hepatology for the primary and secondary prophylaxis of variceal bleeding in portal hypertension.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 40 mg twice daily initially, increasing to 80 mg twice daily depending on heart rate response

Route: Oral

Frequency: Twice daily

Max: 160 mg twice daily

Portal hypertension (SPC 4.2): dosage should be titrated to achieve approximately a 25% reduction in resting heart rate. Dosage should begin with 40 mg twice daily, increasing to 80 mg twice daily depending on heart rate response; if necessary, the dose may be increased incrementally to a maximum of 160 mg twice daily. Elderly: evidence relating blood level to age is conflicting — propranolol should be used with caution in the elderly, treatment should start with the lowest dose and the optimum dose determined individually according to clinical response. Abrupt withdrawal of beta-blockers is to be avoided — withdraw the dosage gradually over 7 to 14 days, following patients during withdrawal, especially those with ischaemic heart disease. Since the half-life may be increased in patients with significant hepatic or renal impairment, caution must be exercised when starting treatment and selecting doses. Paediatric population: this SPC gives paediatric oral doses only for other indications — dysrhythmias, phaeochromocytoma and thyrotoxicosis 0.25 to 0.5 mg/kg three or four times daily; migraine under 12 years 20 mg two or three times daily and over 12 years the adult dose; Fallot tetralogy up to 1 mg/kg repeated three or four times daily. NO paediatric portal hypertension dose is stated.

Dose adjustments

Renal

No specific renal dose adjustment is stated. Because the half-life may be increased in patients with significant hepatic or renal impairment, caution must be exercised when starting treatment and selecting doses (SPC 4.4).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
History of bronchial asthma or bronchospasm
Bradycardia
Cardiogenic shock
Hypotension
Metabolic acidosis
After prolonged fasting
Severe peripheral arterial circulatory disturbances
Second or third degree heart block
Sick sinus syndrome
Untreated phaeochromocytoma
Uncontrolled heart failure
Prinzmetal angina
Patients prone to hypoglycaemia or with restricted counter-regulatory reserves (e.g. malnutrition, prolonged fasting, starvation, chronic liver disease, diabetes, concomitant drugs blocking the response to catecholamines)

Side effects

Sleep disturbances and nightmares (common)
Bradycardia, cold extremities, Raynaud phenomenon (common)
Fatigue and/or lassitude, often transient (common)
Gastrointestinal disturbance such as nausea, vomiting, diarrhoea (uncommon)
Bronchospasm in patients with bronchial asthma or a history of asthmatic complaints, sometimes with fatal outcome (rare)
Hypoglycaemia (frequency not known) in neonates, infants, children, elderly patients, patients on haemodialysis, patients on concomitant antidiabetic therapy, patients with prolonged fasting and patients with chronic liver disease; seizure linked to hypoglycaemia

Interactions

Calcium channel blockers with negative inotropic effects (e.g. verapamil, diltiazem) — should not be used in combination; risk of severe hypotension, bradycardia and cardiac failure, particularly with impaired ventricular function or SA/AV conduction abnormalities. Neither drug should be administered intravenously within 48 hours of discontinuing the other (SPC 4.4)
Hypoglycaemic therapy in diabetic patients — caution; propranolol may block or modify the signs and symptoms of hypoglycaemia (especially tachycardia) and may prolong the hypoglycaemic response to insulin (SPC 4.4)
Adrenaline used to treat allergic reactions — patients with a history of anaphylactic reaction may have a more severe reaction and may be unresponsive to usual adrenaline doses (SPC 4.4)
Note: SPC section 4.5 was not captured in this source bundle — interactions above are drawn from section 4.4

Clinical monograph

How it works

By blocking beta-1 and beta-2 adrenoceptors it reduces cardiac output and produces unopposed alpha-mediated splanchnic vasoconstriction, lowering portal venous inflow and portal pressure.

Prescribing in practice

The dose is titrated to the maximum tolerated level guided by heart rate and blood pressure rather than for blood pressure control, and it should not be used in patients with refractory ascites or marked hypotension where it may worsen outcomes.
Non-selective beta-blockade can mask hypoglycaemia and is contraindicated in asthma and uncontrolled heart failure or significant bradycardia.
Do not stop abruptly, as rebound effects can occur; review tolerability in decompensated cirrhosis.

Monitoring

Titrate against resting heart rate and blood pressure, reviewing tolerance particularly in those with ascites or progressive liver decompensation.

Counselling the patient

This medicine is to reduce pressure in the veins around your gullet and lower bleeding risk, not for blood pressure alone.
Do not stop taking it suddenly without medical advice.
Report breathlessness, wheeze, marked dizziness or a very slow pulse.

Evidence & guidelines

Non-selective beta-blockers reduce variceal bleeding risk in portal hypertension, supported by meta-analyses and reflected in Baveno consensus and liver society guidance.

Reference: BAVENO VII Consensus 2022; BSG Portal Hypertension Guidelines; NICE; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways