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Long-acting propranolol in essential tremor.

Long-acting propranolol (propranolol-LA) was compared with propranolol in divided doses in 18 patients with essential tremor. Three patients were unresponsive to both preparations. Propranolol-LA was preferred by 87% of patients for ease of administration and by 67% for tremor control. Propranolol-LA provided similar (53%), and in some patients greater (47%), reduction of tremor amplitude than divided dosing. Propranolol-LA should be a useful drug in essential tremor.

Humans↗

Influence of the light schedule on the toxic interaction between propranolol and disopyramide in chick embryos.

The effect of the light schedule on toxic interactions between propranolol and disopyramide were studied in chick embryos. Fertilized eggs of White Leghorns were incubated under dark conditions and investigated, on two occasions, under light conditions or under dark conditions. Propranolol, with and without disopyramide, was injected into the air sac of fertilized eggs on the 16th day of incubation. Electrocardiograms (ECGs) were recorded 0 to 60 min after the injection. After the injection of propranolol with disopyramide, the heart rate was significantly decreased compared with the injection of propranolol alone under light conditions. In addition, this toxic interaction between propranolol and disopyramide was more severe under dark conditions than under light conditions. These findings indicate that manipulation of the light schedule has a marked influence on the toxic interaction between propranolol and disopyramide in chick embryos.

Adrenergic beta-Antagonists↗

Influence of the route of administration on the mean hepatic extraction ratio of propranolol in the rat.

The mean hepatic extraction ratio (ER) of propranolol was estimated directly by simultaneous measurements of arterial and hepatic venous blood concentrations of the drug following systemic venous and portal venous administration in the rat. The ER was greater than 0.9 in the dose range of 2.5 to 12.5 mg/kg following rapid infusion of propranolol into the femoral vein and was not dependent on infusion rate. On the other hand, the ER following intraportal constant-rate infusion decreased progressively with increasing dose, although the ER at an intraportal dose of 2.5 mg/kg was as high as that found after administration into the femoral vein. In addition, it was found that the ER at an intraportal dose of 12.5 mg/kg of propranolol was significantly influenced by infusion rate. The unusual AUC-dose relationship of propranolol previously reported in the rat could be explained on the basis of the present nonlinear hepatic extraction depending on the route and rate of administration which was clarified in vivo. The nonlinear hepatic extraction was further confirmed by determining the remarkably decreased ER of (14)C-propranolol given intravenously after pretreatment or during portal venous administration of unlabelled propranolol.

Animals↗

Effects of KRN4884 (a novel K+ channel opener), levcromakalim, nilvadipine and propranolol on endothelin-1-induced heart disorders in anesthetized rats.

The effects of KRN4884 (5-amino-N-[2-(2-chrolophenyl)ethyl]-N'-cyano-3-pyridinecarboxa midine), a novel K+ channel opener, on the electrocardiogram changes caused by the intracoronary administration of endothelin-1 (ET-1) were studied in anesthetized rats and compared with the effects of levcromakalim, a K+ channel opener; nilvadipine, a Ca2+ antagonist; and propranolol, a beta-adrenoceptor antagonist. KRN4884 (50 microg/kg, i.v.) and levcromakalim (300 microg/kg, i.v.) inhibited the ST segment elevation and the development of arrhythmias induced by ET-1 (5 microg, i.c.) and decreased the incidence of death. Nilvadipine (300 microg/kg, i.v.) and propranolol (1000 and 3000 microg/kg, i.v.) each prevented the ST segment elevation, but the suppressions of the occurrence of arrhythmias produced by nilvadipine and propranolol were less than that shown by KRN4884. KRN4884 (30 and 50 microg/kg, i.v.), levcromakalim (100 and 300 microg/kg, i.v.) and nilvadipine (100 and 300 microg/kg, i.v.) significantly decreased the mean blood pressure in a dose-dependent manner, but propranolol did not. The heart rate was decreased by nilvadipine (100 and 300 microg/kg, i.v.) and propranolol (1000 and 3000 microg/kg, i.v.), but was not affected by KRN4884 (30 and 50 microg/kg, i.v.) or levcromakalim (100 and 300 microg/kg, i.v.). These results suggest that pretreatments with KRN4884 and levcromakalim are more effective on ET-1-induced electrocardiogram changes than those with nilvadipine and propranolol.

Anesthesia↗

Propranolol-exacerbated mesenteric ischemia in a patient with hyperthyroidism.

OBJECTIVE: To report a case of acute mesenteric ischemia associated with the use of oral propranolol. CASE SUMMARY: A 59-year-old white man was admitted to the hospital with chronic diarrhea and weight loss. The patient was diagnosed as having hyperthyroidism. Therapy with propylthiouracil 100 mg 3 times daily and propranolol 20 mg twice daily was initiated on an outpatient basis. The following day, the patient was readmitted to our hospital with increased abdominal pain and bloody diarrhea. Angiography revealed superior mesenteric artery occlusion. Antegrade aorta-mesenteric bypass surgery was performed for revascularization, and the patient was discharged 10 days after the surgery. The patient was well both clinically and endoscopically at a follow-up visit 8 months later. DISCUSSION: Although mesenteric ischemia is a devastating illness of varied causes, drug-associated mesenteric ischemia is rarely seen. By decreasing cardiac output and selective vasodilatory receptor inhibition in the splanchnic circulation, propranolol can cause a decline in splanchnic blood flow. An objective causality assessment indicated that propranolol was the possible cause of the arterial occlusion. CONCLUSIONS: Propranolol may rarely be associated with mesenteric ischemia. In cases of newly developed acute abdomen undergoing propranolol therapy, physicians should be aware of this rare and serious adverse reaction to this drug.

Adrenergic beta-Antagonists↗

Effect of propranolol on respiratory function and exercise tolerance in patients with chronic obstructive lung disease.

Ten patients with chronic obstructive lung disease (COLD) (group 1) and five patients with combined COLD and cardiac disease (group 2) were studied at rest and during exercise after an intravenous (IV) slaine control followed by IV propranolol (0.2 mg/kg). During rest propranolol did not alter significantly measurements of lung volume in groups 1 or 2. Following propranolol the mean airway resistance (AR) in group 1 increased from 4.49 to 5.2 cm H2O/L/sec (P smaller than 0.02) and airway conductance (Gaw) decreased from 0.28 to 0.24 L/sec-1 cm. H2O1 (P smaller than 0.02). In group 2 following propranolol, the mean AR increased from 3.60 to 4.67 cm H2O1 (P smaller than 0.05), and Gaw decreased from 0.30 to 0.23 L/sec-1/cm H2O1 (P smaller than 0.05). During exercise, from control to propranolol, the heart rate (HR), blood pressure (BP), and heart rate blood pressure (HR x BP) decreased significantly for both groups 1 and 2 except for the systolic pressure in group 2. The duration of exercise and exercising PO2 were not significantly altered from control to propranolol in groups 1 and 2, indicating that the small but statistically significant changes in AR and Gaw did not interfere with symptom tolerated maximal exercise in these patients and were therefore not clinically important.

Airway Resistance↗

Combined administration of nitroglycerin and propranolol to patients with acute myocardial infarction.

Hemodynamic effects of combined nitroglycerin and propranolol administration were investigated in patients with acute myocardial infarction. After nitroglycerin infusion decreased the mean arterial pressure by 20 mm Hg for one hour, nitroglycerin was continued, and patients were given 0.033 mg/kg of propranolol every five minutes for a total dose of 0.1 mg/kg, or until there was a decrease in heart rate to less than 60 beats/min, an increase in left ventricular filling pressure (LVFP) to greater than 15 mm Hg, or a decrease in systolic arterial pressure to less than 85 mm Hg. Seven of eight patients with initial LVFP less than or equal to 15 mm Hg and three of seven with initial LVFP greater than 15 mm Hg received 0.1 mg/kg of propranolol. Propranolol significantly decreased heart rate. Although pressure time/minute decreased significantly, the magnitude of its decrease was small, suggesting only a minimal effect on myocardial oxygen demands. The LVFP increased after giving propranolol but remained less than the control value. Simultaneous administration of nitroglycerin likely prevented further increases, since LVFP increased after cessation of nitroglycerin infusion, and three patients subsequently had pulmonary edema. Propranolol administration resulted in a significant increase in peripheral vascular resistance and a decrease in cardiac output.

Blood Pressure↗

Time-dependent effects of maternal continuous propranolol on fetal lung development in rats.

Previous studies have demonstrated a role for the beta-adrenergic system in the maturation of the fetal alveolar epithelium. Chronic blockade of beta-adrenergic binding sites has been shown to adversely effect physiologic and biochemical indices of fetal lung maturation. In the present study timed-pregnant female Sprague-Dawley rats were treated with a continuous 0.5 mg/hr dose of propranolol HCl, or saline, via an osmotic pump. The treatment periods were days 18-21, or 20-23 of gestation. Fetal body weights were obtained, and the morphology of the fetal lungs studied by light and electron microscopy. Cytoplasmic volume densities of lamellar inclusion bodies and glycogen within developing type II alveolar epithelial cells were also determined. In addition, total phospholipids (as phosphorus) and glycogen content were determined biochemically. The fetuses from females treated from day 20-23 demonstrated no differences between saline-treated and propranolol-treated groups, in either fetal weight or the morphologic appearance of the developing lung. In contrast, the fetuses from mothers treated from day 18-21 with propranolol were significantly smaller, and their lungs appeared less mature than saline-treated counterparts. The glycogen content of developing type II alveolar epithelial cells was significantly more abundant (as judged by stereologic and biochemical analyses) in the propranolol-treated fetuses. In addition, total phospholipids were decreased in the propranolol-treated 21-day fetuses. The results of the present study suggest that the development of the alveolar epithelium is sensitive to continuous beta-adrenergic blockade by propranolol during a critical time late in gestation.

Adrenergic beta-Antagonists↗

Evaluation of propranolol-glucagon test.

A propranolol-glucagon test was evaluated in 24 control normal children, 21 pituitary dwarfs, 15 patients with constitutional short stature, 2 with chromosome aberration and 4 with miscellaneous diseases. The dose of glucagon enough for the stimulation of human growth hormone (HGH) secretion is more than 20 microgram/kg of body weight. During the test in the control subjects the serum HGH level increased from 2.3 +/- 1.2 ng/ml to a maximum level of 30.0 +/- 15.1 ng/ml, when 10 mg propranolol, regardless of body weight and 30 microgram glucagon per kg of body weight are given. The dose of propranolol administered ranged from 0.2 to 1.0 mg/kg of body weight in normal children studied. Serum 11-OHCS also increased significantly from 14.5 +/- 11.2 microgram/100 ml to 30.1 +/- 15.5 microgram/100 ml (P less than 0.01). There was no difference in the maximum level of urinary total catecholamines in propranolol-glucagon test between 7 pituitary dwarfs and 7 control subjects. The mechanism of HGH response to propranolol-glucagon administration is unknown, but propranolol-glucagon administration is a sensitive and reliable provocative test for HGH secretion, since false negative response of HGH are not observed in patients with non-pituitary disease.

11-Hydroxycorticosteroids↗

Effects of propranolol on GH responsiveness to repeated GH-releasing hormone stimulations in normal subjects.

The influence of beta-adrenergic blockade by oral propranolol on the variability of GH responses to GHRH and on GH responsiveness to repeated GHRH administrations was investigated. Eight normal volunteers underwent three tests on three separate occasions. Each test consisted of two administrations of 80 micrograms GHRH at 2-h intervals without other medication (test 1) or combined with oral administration of 80 mg propranolol 90 min before the first (test 2) or the second GHRH injection (test 3). In test 1 GH levels increased significantly after the first, but not the second GHRH bolus (net incremental area under the curve [nAUC], mean +/- SD: 1453 +/- 974 and 178 +/- 309 micrograms.l-1.(120 min)-1, respectively). In test 2 basal GH secretion was not influenced by propranolol administration, whereas the GH response to the first GHRH injection was significantly greater than in test 1 (2327 +/- 1814 micrograms.l-1.(120 min)-1; p less than 0.05). However, individual subjects showed the same variability of GH response as in test 1. The GH response to the second GHRH bolus remained negligible. In test 3 administration of propranolol 90 min before the second GHRH bolus led to a clear GH increase (690 +/- 1002 micrograms.l-1.(120 min)-1), not significantly different from the GH response to the first bolus (1796 +/- 1375 micrograms.l-1.(120 min)-1). However, only 4 subjects showed a marked restoration of the GH responsiveness to the second GHRH administration. In conclusion, oral administration of propranolol is able to increase GH responsiveness to GHRH without changing the great individual variability. The response to a repeated GHRH stimulation is only partially restored by propranolol.

Administration, Oral↗

Electrophysiologic effects of propranolol on the human heart.

Effects of propranolol (10(-9) to 10(-4) Gm/ml) on various electrophysiologic properties of human papillary muscles obtained from patients undergoing corrective open heart surgery were studied to have an insight into the mechanism of its antiarrhythmic activity in man. Propranolol (10(-8) to 10(-6) Gm/ml) produced significant decreases in the action potential duration, effective refractory period and dv/dt of depolarization phase of action potential without significantly affecting the resting potential and amplitude of action potential. These effects were concentration dependent. High concentration (10(-4) Gm/ml) of propranolol not only produced greater decreases in the above parameters but also reduced the resting potential and amplitude of action potential. Although propranolol decreased both the action potential duration and effective refractory period, the shortening of the action potential duration was greater than the shortening of the effective refractory period. It shifted the membrane responsiveness curve to the right and down. It produced frequency dependent decreases in the dv/dt of phase 0 of action potential and the rate of repolarization. Propranolol also increased the threshold of stimulation. Propranolol produced electrophysiologic changes in the human myocardium qualitatively similar to those in canine myocardium. The probable mechanism of its antiarrhythmic activity in man has been discussed.

Action Potentials↗

Increased number of beta-adrenoceptors in cultured heart cells after propranolol withdrawal.

We have studied the effects of propranolol on the number and function of beta-adrenoceptors of cultured heart cells from mice. After 24 hrs in culture, heart cells were incubated for 48 hrs with either standard medium or medium containing propranolol. After a washing period of 30 min, beta-adrenoceptors were measured with a receptor binding assay. The dissociation constant (Kd) did not differ between control and cultured heart cells pretreated with propranolol. By contrast, the maximum number of binding sites (Bmax) was 2.5 times higher in propranolol-pretreated than control cultured heart cells. The increase in the rate of beating and the elevation of cyclic AMP content induced by 10(-5) M isoproterenol were significantly higher for cultured cells pretreated with propranolol than for control cells. These results indicate a correlation between an increased number of beta-adrenoceptors and increased physiological responses of cultured heart cells after propranolol withdrawal.

Animals↗

Cardiopulmonary bypass alters the pharmacokinetics of propranolol in patients undergoing cardiac surgery.

The pharmacokinetics of propranolol may be altered by hypothermic cardiopulmonary bypass (CPB), resulting in unpredictable postoperative hemodynamic responses to usual doses. The objective of the present study was to investigate the pharmacokinetics of propranolol in patients undergoing coronary artery bypass grafting (CABG) by CPB under moderate hypothermia. We evaluated 11 patients, 4 women and 7 men (mean age 57 +/- 8 years, mean weight 75.4 +/- 11.9 kg and mean body surface area 1.83 +/- 0.19 m(2)), receiving propranolol before surgery (80-240 mg a day) and postoperatively (10 mg a day). Plasma propranolol levels were measured before and after CPB by high-performance liquid chromatography. Pharmacokinetic Solutions 2.0 software was used to estimate the pharmacokinetic parameters after administration of the drug pre- and postoperatively. There was an increase of biological half-life from 4.5 (95% CI = 3.9-6.9) to 10.6 h (95% CI = 8.2-14.7; P < 0.01) and an increase in volume of distribution from 4.9 (95% CI = 3.2-14.3) to 8.3 l/kg (95% CI = 6.5-32.1; P < 0.05), while total clearance remained unchanged 9.2 (95% CI = 7.7-24.6) vs 10.7 ml min(-1) kg(-1) (95% CI = 7.7-26.6; NS) after surgery. In conclusion, increases in drug distribution could be explained in part by hemodilution during CPB. On the other hand, the increase of biological half-life can be attributed to changes in hepatic metabolism induced by CPB under moderate hypothermia. These alterations in the pharmacokinetics of propranolol after CABG with hypothermic CPB might induce a greater myocardial depression in response to propranolol than would be expected with an equivalent dose during the postoperative period.

Adrenergic beta-Antagonists↗

Antiarrhythmic therapy with flecainide in combination and comparison with propranolol.

In a prospective study of 10 patients with chronic ventricular arrhythmias, flecainide 50mg tid and propranolol 20mg tid were administered, alone and in combination, in a crossover design. Before and after each treatment phase, routine ECG and 24-hour ECG were recorded, morning plasma concentrations of the drugs were measured, and side effects recorded. Treatment with flecainide alone resulted in a 38% mean reduction (p less than 0.05) of ventricular premature complexes, a 75% (p less than 0.01) mean reduction of couplets, and elimination of ventricular tachycardia. At the dosage administered, propranolol alone had no antiarrhythmic effect. The combination of flecainide and propranolol showed no additional therapeutic benefit although there was a small, but not significant, increase in ventricular premature complexes and couplets. Use of flecainide resulted in a 12% widening of the QRS complex, with no significant change in PQ time, QTc and heart rate. Combined therapy with propranolol and flecainide resulted in a 12% decrease of average heart rate. The same effect was achieved when propranolol was given alone. The average plasma concentration of flecainide increased by 25% during combined therapy with propranolol. There were few side effects related to flecainide at the dosage administered and no additional side effects were recorded during the combined treatment.

Adult↗

Induction of propranolol metabolism by Ginkgo biloba extract EGb 761 in rats.

Ginkgo biloba is one of the most popular herbal medicines in the world, due to its purported pharmacological effects, including memory-enhancing, cognition-improving, and antiplatelet effects. When used in the elderly, Ginkgo has a high potential for interactions with cardiovascular drugs. This study aimed to investigate the effects of the standard Ginkgo biloba extract (EGB 761) treatment on the pharmacokinetics of propranolol and its metabolism to form N-desisopropylpropranolol (NDP) in rats. We also examined the activity and expression of cytochrome P450 (CYP) 1A and other CYPs in rats treated with EGb 761 at 10 and 100 mg/kg/day for 10 days. A single oral dose of propranolol (10 mg/kg) was administered on day 11 and the concentrations of both propranolol and NDP were determined using validated liquid chromatography-mass spectrometry (LC-MS) methods. The levels of mRNA and protein of various CYPs were determined by RT-PCR and Western blotting analysis, respectively. Pretreatment of EGb 761 at 100 mg/kg, but not 10 mg/kg, for 10 days significantly reduced the area under the plasma concentration-time curve (AUC) and maximum plasma concentration (Cmax) of propranolol, whereas those values of NDP were significantly increased. CYP1A1, 1A2, 2B1/2, and 3A1 activities and gene expression in the rat liver were significantly increased in a dose-dependent manner by pretreatment with EGb 761. The ex-vivo formation of NDP in liver microsomes from rats pretreated with EGb 761 was markedly enhanced. The formation of NDP from propranolol in liver microsomes was significantly inhibited by alpha-naphthoflavone (ANF, a selective CYP1A2 inhibitor), but not by quinidine (a CYP2D inhibitor). These results indicated that EGb 761 pretreatment decreased the plasma concentrations of propranolol by accelerated conversion of parental drug to NDP due to induction of CYP1A2. EGb 761 pretreatment also significantly induced CYP2B1/2 and CYP3A1, suggesting potential interactions with substrate drugs for these two enzymes. Further study is needed to explore the potential for gingko-drug interactions and the clinical impact.

Animals↗

Endoscopic, portographic, and hemodynamic evaluation of prolonged propranolol administration in pigs with experimental portal hypertension and esophageal varices.

The effect of long-term propranolol administration on esophageal varices, portocollateral shunting, portal pressure, hepatosplanchnic hemodynamics, and liver function was studied in a pig model with experimentally induced prehepatic portal hypertension and esophageal varices. Five pigs were treated with 160 mg propranolol daily from week 5 to week 24 after portal-vein banding, and five pigs served as nontreated controls. Administration of propranolol caused an initial, significant reduction (20%) of portal venous pressure, followed by a gradual increase to levels not different from control pressures. In contrast, a marked reduction of the caliber of the coronary vein and size of the esophageal varices was noticed. Twenty weeks of propranolol treatment did not change liver blood flow or liver function. We conclude that the size of the varices rather than portal venous pressure depicts the effect of propranolol treatment and suggest that the beneficial effect of propranolol on variceal bleeding can be explained by a reduction in the wall tension of the varices, initiated and maintained by a diminution of splanchnic blood flow.

Animals↗

Preliminary report of the effects of propranolol HCl on the discomfiture caused by niacin.

Subjective discomfort caused by nausea and hot, pruritic skin has been described in patients after ingestion of therapeutic dosages of niacin is shown by this study to be alleviated by propranolol HC1. A dosage of 2 mg, I.V., given incrementally, in a clinical trial of six patients is described. The peripheral vasodilator effects of niacin were attenuated in some subjects but not in others. However, all subjects reported relief of unpleasant symptoms. Serial vital signs were taken and no significant changes were found. It is postulated that propranolol HC1 exerts a calmative effect at the CNS level. In a series that utilized doses of 40 and 80 mg of propranolol HC1 taken orally 30 min prior to the ingestion of 500 or 1000 mg of niacin, a progressive increase in the onset of the niacin flush was observed. It is proposed that as the available plasma level of propranolol HC1 falls, the ratio of niacin to propranolol HC1 increases, exceeding the threshold at which the flush occurs. Both these studies suggest that further work is indicated to establish the possible therapeutic efficacy of propranolol HC1.

Clinical Trials as Topic↗

Effect of propranolol on heart rate variability in patients with end-stage renal disease: a double-blind, placebo-controlled, randomized crossover pilot trial.

BACKGROUND: Low heart rate variability (HRV) is an independent risk factor of cardiac mortality in patients with end-stage renal disease (ESRD). It has been explained by uremic parasympathetic neuropathy. Sympathetic overactivity can also reduce HRV. Our aim was to determine whether there is vagal activity in ESRD patients that is masked by sympathetic activity. METHODS: The effect of propranolol on HRV was examined in 13 patients with ESRD, aged 20.1 +/- 7.6 years without diabetes. All patients were given intravenous propranolol (0.05 mg/kg) once and placebo once in a randomized, double-blind way, with an interval of 6.6 days (mean, range: 2-9). Propranolol was administered before hemodialysis treatment, after 40 minutes supine resting period. HRV was registered for 10 minutes, during supine, before and after the injection. Patients' HRV data were compared to that of 29 age-matched healthy controls. RESULTS: Initially, both high-(HFV) and low-frequency (LFV) bands of heart rate variability were lower in ESRD patients compared to controls (p < 0.001 for both). Propranolol resulted in a significant increase of HFV (propranolol: AlgHFV = 0.182 (0.027 - 0.337), placebo: deltalgHFV = -0.029 (-0.128 - +0.070); p = 0.032). Elevation of LFV was not significant. Six patients had an elevated plasma norepinephrine and/or epinephrine level. Plasma dopamine level was elevated in all but 1 patient (mean: 432 pmol/l, 95% CI: 320-543) and showed an inverse relationship with the increase of IgHFV secondary to propranolol (r = -0.66, p = 0.014). CONCLUSIONS: Low HFV of ESRD patients can be improved by beta-adrenergic blockade. It demonstrates that there is some vagal activity in ESRD that is masked by sympathetic activity. Therefore, altered sympathovagal balance of ESRD patients should be taken into consideration in the assessment of vagal uremic neuropathy.

Adolescent↗