Propranolol (Portal Hypertension)

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.