inderal
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Propranolol hydrochloride, marketed under the brand name Inderal, represents one of the foundational beta-blockers in cardiovascular and neurological medicine. As a non-selective beta-adrenergic antagonist, it competitively blocks catecholamine effects at both β1 and β2 adrenergic receptors, producing a wide spectrum of therapeutic actions from heart rate control to anxiety symptom reduction. First synthesized by Sir James Black in 1964, its development marked a turning point in how we approach sympathetic nervous system overactivity.
Inderal: Comprehensive Cardiovascular and Neurological Protection - Evidence-Based Review
1. Introduction: What is Inderal? Its Role in Modern Medicine
Inderal contains the active pharmaceutical ingredient propranolol hydrochloride, classified pharmacologically as a non-selective beta-adrenergic blocking agent. Unlike newer cardioselective beta-blockers, Inderal affects both cardiac (β1) and pulmonary/vascular (β2) receptors, giving it a unique therapeutic profile that remains relevant decades after its introduction. What is Inderal used for? The medication has FDA-approved indications for hypertension, angina pectoris, cardiac arrhythmias, myocardial infarction prophylaxis, essential tremor, and migraine prophylaxis. Off-label applications span performance anxiety, thyroid storm management, and portal hypertension complications.
The significance of Inderal in modern therapeutics lies in its dual cardiovascular and central nervous system effects. While newer agents have emerged, many specialists still consider Inderal the gold standard for certain conditions like essential tremor where its non-selectivity provides particular benefit. The benefits of Inderal extend beyond simple receptor blockade to include membrane-stabilizing properties and potential neuroprotective effects that continue to be investigated.
2. Key Components and Bioavailability of Inderal
The composition of Inderal centers on propranolol hydrochloride as the sole active component, typically formulated with excipients like lactose, magnesium stearate, and cellulose derivatives in oral tablets. The standard release form comes in tablets ranging from 10mg to 80mg, while a long-acting formulation (Inderal LA) provides sustained 24-hour coverage with once-daily dosing.
Bioavailability of Inderal presents a clinically significant consideration. Oral propranolol undergoes extensive first-pass metabolism in the liver, resulting in approximately 25% systemic availability. This hepatic clearance creates substantial interpatient variability in effective dosing. The medication is highly protein-bound (90%) and lipophilic, allowing it to cross the blood-brain barrier readily - a property that underlies its CNS effects. Peak plasma concentrations occur within 1-4 hours post-ingestion, with elimination half-life of 3-6 hours in standard formulations.
The pharmacokinetics explain why titration must be individualized. A patient’s hepatic function, concomitant medications, and genetic metabolic profile all influence the effective dosage. This is why we start low - often 10mg TID - and gradually escalate based on therapeutic response and tolerance.
3. Mechanism of Action: Scientific Substantiation
Understanding how Inderal works requires examining its effects at multiple physiological levels. The primary mechanism involves competitive antagonism of beta-adrenergic receptors, preventing catecholamines (epinephrine, norepinephrine) from binding and activating the sympathetic nervous system cascade.
At the cardiac level, Inderal reduces heart rate, decreases myocardial contractility, and suppresses conduction velocity through the AV node. These combined effects lower cardiac output and myocardial oxygen demand - the fundamental basis for its anti-anginal properties. In hypertension, the mechanism involves reduced cardiac output, inhibition of renin release from juxtaglomerular cells, and potentially central nervous system effects that diminish sympathetic outflow.
The neurological effects operate through both peripheral and central pathways. For essential tremor, Inderal likely reduces tremor amplitude by blocking peripheral β2 receptors in skeletal muscle. Its migraine prophylaxis benefits may derive from cerebral vasoconstriction via unopposed alpha-receptor activity, or through inhibition of cortical spreading depression. The anti-anxiety effects appear related to reduced peripheral symptoms of anxiety (palpitations, tremor) that feedback to diminish psychological distress.
The scientific research behind these mechanisms is robust, with hundreds of studies validating the pharmacological actions. What’s fascinating is that we’re still discovering new applications - recent investigations explore Inderal’s potential in treating PTSD nightmares and chemotherapy-related anxiety.
4. Indications for Use: What is Inderal Effective For?
Inderal for Hypertension
As monotherapy or combination treatment, Inderal effectively lowers blood pressure through multiple mechanisms. The 2017 ACC/AHA hypertension guidelines still recognize beta-blockers as acceptable first-line agents for specific patient subgroups, particularly those with compelling indications like post-MI status or heart failure. The typical starting dose for hypertension is 40mg twice daily, with maintenance doses ranging from 120-240mg daily in divided doses.
Inderal for Angina Pectoris
By reducing myocardial oxygen demand, Inderal decreases angina frequency and improves exercise tolerance. The medication allows patients to achieve higher workloads before experiencing ischemic symptoms. Dosing for angina typically begins at 80-320mg daily in divided doses, with careful monitoring for excessive bradycardia.
Inderal for Cardiac Arrhythmias
Inderal remains particularly valuable for catecholamine-induced arrhythmias, including those associated with thyrotoxicosis, pheochromocytoma, and digitalis toxicity. It effectively suppresses supraventricular tachycardias and may control ventricular rate in atrial fibrillation. Antiarrhythmic dosing varies widely based on arrhythmia type and severity.
Inderal for Migraine Prophylaxis
The mechanism for migraine prevention isn’t fully understood but likely involves serotonergic pathways and cortical spreading depression modulation. Dosing typically starts at 80mg daily in divided doses, increasing gradually to 160-240mg daily if needed. Approximately 50-70% of patients experience significant reduction in migraine frequency and severity.
Inderal for Essential Tremor
This represents one of Inderal’s most distinctive applications, often providing dramatic improvement in tremor amplitude and functional capacity. Doses of 120-320mg daily typically reduce tremor magnitude by 50-60% in responsive patients. The non-selective beta-blockade appears crucial for this indication, as cardioselective agents show inferior efficacy.
Inderal for Performance Anxiety
While not FDA-approved for this indication, Inderal has become a mainstream treatment for situational anxiety that manifests with prominent physical symptoms. Doses of 10-40mg taken 30-60 minutes before anticipated stress can effectively control tremor, tachycardia, and vocal instability without affecting cognitive performance.
5. Instructions for Use: Dosage and Course of Administration
Proper administration of Inderal requires careful individualization based on indication, patient characteristics, and concomitant conditions. The general principle is “start low and go slow” with particular caution in elderly patients and those with compromised hepatic function.
| Indication | Initial Dosage | Maintenance Range | Administration Notes |
|---|---|---|---|
| Hypertension | 40mg BID | 120-240mg daily in 2-3 divided doses | May increase to 640mg daily in resistant cases |
| Angina | 80-320mg daily in 2-4 divided doses | 160-240mg daily | Titrate until angina control or unacceptable bradycardia |
| Arrhythmias | 10-30mg TID-QID | 30-120mg daily in divided doses | Higher doses for life-threatening arrhythmias |
| Migraine | 80mg daily in divided doses | 160-240mg daily | 4-6 week trial to assess efficacy |
| Essential Tremor | 40mg BID | 120-320mg daily | Divide doses to maintain 24-hour coverage |
| Performance Anxiety | 10-40mg single dose | As needed | Administer 30-60 minutes before anticipated stress |
The course of administration varies by indication. For chronic conditions like hypertension, indefinite treatment is typical with periodic reassessment. For migraine prophylaxis, we often recommend 6-month trials followed by attempts at dose reduction. Essential tremor typically requires continuous therapy, while performance anxiety utilizes intermittent, as-needed dosing.
Abrupt discontinuation of Inderal should be avoided due to potential rebound hypertension, tachycardia, and angina exacerbation. Tapering over 1-2 weeks is recommended, with closer monitoring in patients with coronary artery disease.
6. Contraindications and Drug Interactions
Contraindications for Inderal include:
- Bronchial asthma or history of bronchospasm
- Severe bradycardia (heart rate <50 bpm)
- Cardiogenic shock
- Decompensated heart failure
- Hypersensitivity to propranolol
- Severe peripheral arterial disease
- Pheochromocytoma (unless alpha-blockade established first)
- Metabolic acidosis
Special precautions apply to patients with diabetes, as Inderal can mask hypoglycemia symptoms (tremor, tachycardia) and potentially impair glucose recovery. The medication should be used cautiously in hepatic impairment due to reduced clearance, and dosage adjustment is necessary in severe liver disease.
Drug interactions with Inderal are numerous and clinically significant:
- Antiarrhythmics: Additive bradycardia with digoxin, verapamil, diltiazem
- Antihypertensives: Potentiated hypotension with other BP-lowering agents
- Insulin/Oral hypoglycemics: Altered glucose metabolism and masked hypoglycemia
- NSAIDs: Reduced antihypertensive efficacy
- Sympathomimetics: Mutual antagonism with bronchodilators
- CYP450 inhibitors: Increased propranolol levels with cimetidine, fluoxetine
- CYP450 inducers: Reduced efficacy with rifampin, phenobarbital
Regarding pregnancy, Inderal carries FDA Pregnancy Category C designation, indicating that risk cannot be ruled out. Use during pregnancy requires careful risk-benefit assessment, particularly regarding potential fetal bradycardia, growth restriction, and neonatal hypoglycemia. Breastfeeding is generally considered compatible as propranolol concentrations in milk are low.
7. Clinical Studies and Evidence Base
The evidence base for Inderal spans decades of rigorous investigation. Landmark studies include:
The Beta-Blocker Heart Attack Trial (BHAT) demonstrated 26% reduction in mortality when propranolol was initiated 5-21 days post-MI and continued for 25 months. This 1982 study established beta-blockers as standard post-infarct care.
For essential tremor, multiple randomized controlled trials have confirmed efficacy. A 2001 Neurology publication showed 60% of essential tremor patients achieved clinically significant improvement with propranolol versus 20% with placebo. The average tremor amplitude reduction was 55% in responsive patients.
Migraine prevention studies consistently show propranolol’s superiority to placebo. A comprehensive Cochrane review concluded that propranolol reduces migraine frequency by approximately 50% in responsive patients, with NNT of 3 for 50% reduction in attacks.
The scientific evidence for hypertension management, while established earlier, continues to be validated in contemporary meta-analyses. While newer agents have emerged, propranolol remains particularly effective in younger patients with high-renin hypertension and those with concomitant conditions like migraine or essential tremor.
8. Comparing Inderal with Similar Products and Choosing Quality Medication
When comparing Inderal with other beta-blockers, several distinctions emerge:
Inderal vs. Metoprolol: Metoprolol offers β1 selectivity, making it preferable in patients with pulmonary concerns. However, Inderal’s non-selectivity provides superior efficacy for essential tremor and may offer advantages in migraine prevention.
Inderal vs. Atenolol: Atenolol’s hydrophilicity limits CNS penetration, reducing side effects like fatigue and depression but potentially diminishing efficacy for centrally-mediated indications.
Inderal vs. Nadolol: Both are non-selective, but nadolol’s longer half-life permits once-daily dosing. However, nadolol lacks Inderal’s membrane-stabilizing properties.
Inderal vs. Carvedilol: Carvedilol adds alpha-blockade, creating additional vasodilation but potentially more orthostatic hypotension.
When choosing between brand name Inderal and generic propranolol, bioequivalence studies generally support interchangeability. However, some specialists report observing individual patient responses that favor one manufacturer’s formulation. For critical indications like arrhythmia control, maintaining consistency with a specific manufacturer’s product may be prudent.
Quality considerations include verification of FDA approval, manufacturer reputation, and proper storage conditions. Patients should be counseled to obtain medications from reputable pharmacies and to avoid unauthorized online sources.
9. Frequently Asked Questions (FAQ) about Inderal
What is the recommended course of Inderal to achieve results for migraine prevention?
Most patients require 4-8 weeks of consistent dosing at therapeutic levels (typically 160-240mg daily) to assess full efficacy. We generally continue effective therapy for 6-12 months before attempting gradual dose reduction.
Can Inderal be combined with antidepressant medications?
Yes, with appropriate monitoring. Inderal is frequently combined with SSRIs, particularly for patients with mixed anxiety and cardiovascular symptoms. However, fluoxetine and paroxetine may increase propranolol levels through CYP2D6 inhibition, potentially requiring dose adjustment.
How quickly does Inderal work for performance anxiety?
Single doses typically begin working within 30-60 minutes, with peak effects at 1-2 hours. The duration of action is 4-6 hours for standard formulation, making timing crucial for event-specific dosing.
Is weight gain common with Inderal?
Modest weight gain (2-4 pounds) occurs in approximately 10-15% of long-term users, possibly due to reduced metabolic rate and exercise tolerance. This is generally less pronounced than with some other beta-blockers like atenolol.
Can Inderal be safely discontinued after long-term use?
Abrupt cessation risks rebound tachycardia, hypertension, and angina exacerbation. Tapering over 1-3 weeks is recommended, with closer monitoring in patients with coronary disease. The withdrawal syndrome typically resolves within 1-2 weeks.
10. Conclusion: Validity of Inderal Use in Clinical Practice
Despite decades of clinical use and the introduction of numerous newer agents, Inderal maintains an important position in therapeutic arsenals. Its unique non-selective profile, established efficacy across multiple indications, and generally favorable safety profile (when appropriately prescribed) justify its continued relevance.
The risk-benefit profile strongly supports Inderal use in properly selected patients. Key benefits include proven cardiovascular protection, unique efficacy for essential tremor, and versatile application across both somatic and psychological conditions. Risks primarily involve the contraindications and precautions discussed, particularly bronchospasm in susceptible individuals and withdrawal phenomena with abrupt discontinuation.
For clinicians, Inderal represents a tool of substantial versatility when applied with appropriate patient selection, careful titration, and ongoing monitoring. Its mechanism of action, while conceptually simple, produces complex therapeutic effects that continue to make it indispensable for specific clinical scenarios.
I remember when we first started using propranolol for essential tremor back in the late 90s - we were frankly amazed at how something developed for blood pressure could transform a musician’s career. Sarah, a 42-year-old violinist, came to clinic with tremor so severe she’d been placed on medical leave from the symphony. We started her on 20mg BID, and within two weeks she was back to practicing. By month three, she’d returned to performance. What struck me was how the tremor improvement seemed to unlock her entire personality - she’d been increasingly withdrawn as the tremor worsened.
The migraine application was actually discovered somewhat accidentally - cardiology patients on propranolol for hypertension reported their migraines had improved. We had heated debates in our department about whether to formally study this or dismiss it as anecdotal. Dr. Henderson was adamant it was just the placebo effect, but the nursing staff kept noting the pattern. Eventually we designed a proper trial and the results were undeniable - though the mechanism still isn’t completely understood.
One case that taught me lasting caution was Mark, a 68-year-old with hypertension and mild COPD we inherited from another practice. The previous doctor had him on 80mg BID with good BP control, but Mark had been gradually increasing his inhaler use. It took a direct question about his breathing during follow-up to uncover that he’d been having wheezing for months but didn’t connect it to the medication. We switched him to metoprolol and the respiratory symptoms resolved within days. That experience cemented for me the absolute necessity of specifically asking about respiratory symptoms at every visit.
The longitudinal follow-up has been revealing too. We’ve tracked some essential tremor patients for over a decade now, and what’s interesting is that the efficacy seems sustained without significant dose escalation in most cases. Jennifer, now 71, has maintained on 60mg BID for twelve years with consistent tremor control. She jokes that propranolol has given her back her handwriting and her dignity - she’d stopped writing checks in public because her signature was illegible.
The testimonials we’ve collected over the years consistently highlight two themes: the restoration of functional abilities and the psychological impact of controlling visible symptoms. One young lawyer described finally being able to drink water during tense negotiations without spilling, calling it “getting my professional composure back.” Another patient summarized it perfectly: “It’s not just about steady hands - it’s about steady confidence.”