Propranolol - instructions for use, dose, side effects, contraindications

Blocks beta1 and beta2-adrenergic receptors, has a membrane-stabilizing effect. Oppressing the automatism of the sinoatrial node, suppresses the appearance of ectopic foci in the atria, AV joints, ventricles (to a lesser extent). Reduces the rate of excitation in the AV connection along the bundle of Kent, mainly in the anterograde direction.

After taking a single dose, the hypotensive effect lasts for 20-24 hours. The hypotension is stabilized by the end of the second week of treatment.

Mechanisms of antihypertensive action:

Propranolol, blocking the 1-adrenergic receptor of the heart, reduces cardiac output (reducing the strength and frequency of heart contractions);

Blocking 1-adrenergic receptors in juxtaglomerular kidney cells reduces renin release, resulting in a decrease in the synthesis of angiotensin II, which has pronounced vasoconstrictive properties (renin causes the conversion of angiotensinogen to angiotensin I, which then turns into angiotensin II).

Propranolol restores the sensitivity of the weakened or lost baroreceptor depressor reflex (in hypertensive illness this reflex is suppressed due to a decrease in the sensitivity of the aortic arch baroreceptors).

Reduction of norepinephrine release by endrings of adrenergic fibers (due to blockade of presynaptic β2-adrenergic receptors).

Inhibition of the central links of sympathetic regulation of vascular tone.

The mechanism of antianginal action: urezhaet heart rate, reduces the force of heart contractions, as a result reduces the need for myocardium in oxygen. Reduces renal blood flow and the rate of glomerular filtration.One-time administration of prolonged forms is equivalent to taking several doses of propranolol hydrochloride. With prolonged use reduces venous return, has cardioprotective effect (reliably reduces the risk of repeated myocardial infarction and sudden death by 20-50%). In patients with moderate form of hypertension - reduces the likelihood of developing IHD and cerebral strokes. With IHD reduces the frequency of seizures, increases the tolerance of physical exertion, reduces the need for nitroglycerin. It is most effective in patients of young age (under 40 years) with hyperdynamic type of circulation and with increased content of renin. Increases the tone of the bronchi and contractility of the uterus (reduces bleeding during labor and in the postoperative period), increases secretory and motor activity of the gastrointestinal tract. It inhibits platelet aggregation and activates fibrinolysis. It inhibits lipolysis in adipose tissue, preventing the increase of the level of free fatty acids (wherein the concentration of triglyceride in plasma and increased atherogenic factor. Inhibits glycogenolysis, glucagon and insulin secretion, the conversion of thyroxine to triiodothyronine.Reduces intraocular pressure, reduces the secretion of watery moisture.

The decrease in tremor is mainly due to the block β2adrenoreceptors of skeletal muscles.

Anxiolytic (reducing anxiety, fear, anxiety) is associated with a weakening of somatic symptoms of anxiety.

Prevention of vascular headache (migraine) - due to impeding the expansion of arteries, increasing the concentration of coagulation factors (blockade of β2adrenoreceptors), decreased aggregation and adhesion of platelets, suppression of the release of renin.

Pharmacokinetics:When ingested quickly and almost completely absorbed from the digestive tract (90%). Bioavailability is 30-40% (the effect of "first passage"), depends on the nature of food and intensity of the hepatic blood flow and increases with prolonged admission (metabolites that inhibit liver enzymes are formed). Cmax in plasma is noted after 1-1.5 hours or 6 hours (for the prolonged form). It binds to plasma proteins by 90-95%; the half-life is 2-5 hours (10 hours for the prolonged form). The volume of distribution is 3-5 l / kg. Accumulates in the lung tissue, brain, kidneys, heart, passes through the placental barrier, penetrates into breast milk. It is subjected to glucuronidation in the liver (99%). It is excreted with bile into the intestine, deglycuronatesI and reabsorbed (half-life on the background of the course of administration may extend to 12 hours). Excreted by the kidneys in the form of metabolites.

Indications:Arterial hypertension, angina pectoris, sinus tachycardia (including hyperthyroidism), supraventricular tachycardia, tachysystolicI form atrial fibrillation, supraventricular and ventricular extrasystole, hypertrophic cardiomyopathy, myocardial infarction, mitral valve prolapse, subaortic stenosis, sympathoadrenalNew crisis in patients with diencephalic syndrome, neurocirculatorydystonia, portal hypertension, essential tremor, panic attacks, aggressive behavior, migraine (prophylaxis), ancillary treatment with pheochromocytoma (only in combination with an alpha-adrenoblockagents), thyrotoxicosis (including preoperative preparation), thyrotoxic crisis, primary weakness of labor, menopausal vasomotor symptoms, withdrawal syndrome; treatment of akathisia caused by neuroleptics.

ICD-10

V.F40-F48.F40.0 Agoraphobia

V.F40-F48.F40.1 Social phobia

V.F40-F48.F40.2 Specific (isolated) phobias

V.F40-F48.F41.0 Panic disorder [episodic paroxysmal anxiety]

V.F40-F48.F41.1 Generalized anxiety disorder

V.F40-F48.F43.2 Disorder of adaptive reactions

V.F40-F48.F45 Somatoform disorders

VI.G40-G47.G43 Migraine

IX.I10-I15.I10 Essential [primary] hypertension

IX.I10-I15.I15 Secondary Hypertension

IX.I20-I25.I20 Angina pectoris [angina pectoris]

IX.I20-I25.I20.0 Unstable angina

IX.I20-I25.I25 Chronic ischemic heart disease

IX.I30-I52.I34.1 Prolapse [prolapse] of the mitral valve

IX.I30-I52.I47.1 Nadzheludochkovaya tachycardia

IX.I30-I52.I49.9 Disorder of heart rhythm, unspecified

XIV.N80-N98.N95.1 Menopause and menopause in women

XV.O60-O75.O62.2 Other types of weakness in labor

XVIII.R25-R29.R25.1 Tremor, unspecified

XVIII.R40-R46.R45.6 Physical aggressiveness

Contraindications:Hypersensitivity(systolic BP less than 90 mm Hg, especially with myocardial infarction), acute and severe chronic obstructive pulmonary disease heart failure (IIB-III stage), acute myocardial infarction (systolic blood pressure less than 100 mmHg), pulmonary edema, prinzmetal angina, cardiogenic shock, cardiomegaly (no signs of heart failure), vasomotor rhinitis, diabetes mellitus, obliterating vascular diseases, metabolic acidosis, bronchial asthma, chronic obstructive pulmonary disease,pheochromocytoma (without simultaneous use of alpha-adrenoblockagents), spastic colitis, simultaneous administration with antipsychoticmeans and anxiolytics (chlorpromazine, trioxazine, etc.), MAO inhibitors, lactation period.

Carefully:Hyperthyroidism, chronic bronchitis, emphysema, heart failure, pheochromocytoma, hypoglycaemia, acidosis, hepatic and renal dysfunction, psoriasis, myasthenia gravis, allergic reactions in history, pregnancy, Raynaud's syndrome, old age, under 18 years of age (efficacy and safety not established).

Pregnancy and lactation:

Recommendations FDA category C. Increased risk of hypoglycemia, respiratory depression, bradycardia and hypotension in the fetus and newborn. Application inIt is possible, if the expected effect of therapy exceeds the potential risk to the fetus

Penetrates into breast milk. Apply if the benefits exceed the risk of side effects.

Dosing and Administration:

Intravenously streamwise, slowly, for adults, for arresting arrhythmia, thyrotoxic crisis, acute ischemia - 1 mg for 1 minute, if necessary again with an interval of 2 min (under the control of ECG and blood pressure).The maximum dose is 10 mg.

Inside before eating, squeezed with liquid or semi-liquid food (water, juice, apple puree, pudding), adults: with arterial hypertension - the initial dose of 80 mg 2 times a day, maintaining a dose of 160-320 mg. Prolonged forms: 80 mg once a day, if necessary up to 120-160 mg once, under the control of blood pressure. At arrhythmias - 10-30 mg 3-4 times a day, with subaortal stenosis - 20-40 mg 3-4 times a day. With portal hypertension, angina, migraine, excitation, tremor, the initial dose of 40 mg 2-3 times a day, supporting - 160, 120-240, 80-160, 80-120, 80-160 mg / day, respectively. When pheochromocytoma - 30-60 mg / day for 3 days (before surgery). With myocardial infarction - from 5 to 21 days after a heart attack 40 mg 4 times a day for 2-3 days, then - 80 mg 2 times a day. For the stimulation of labor - 20 mg every 30 minutes 4-6 times (80-120 mg / day), for the prevention of postpartum bleeding - 20 mg 3 times a day for 3-5 days. When glaucoma is intra-conjunctival to the affected eye.

For children: Inside, the initial dose: 0.5-1 mg / kg / day, supporting - 2-4 mg / kg / day in 2 divided doses.

Side effects:

From the side of the cardiovascular system and blood (hematopoiesis, hemostasis): bradycardia, heart failure, AV blockade, hypotension, peripheral circulatory disturbance, thrombocytopenic purpura, leukopenia, agranulocytosis.

From the nervous system and sensory organs: asthenia, dizziness, headache, insomnia, drowsiness, nightmares, decreased speed of mental and motor reactions, emotional lability, depression, excitement, hallucinations, disorientation in time and space, short-term amnesia, increased fatigue, weakness, violation of sensitivity, paresthesia; dry eyes, eye disorders, keratoconjunctivitis.

On the part of the digestive system: nausea, vomiting, abdominal pain, diarrhea or constipation, mesenteric artery thrombosis, ischemic colitis, violations of the liver (dark urine, icterus sclera or skin, cholestasis), changes in taste.

On the part of the respiratory system: pharyngitis, rhinitis, nasal congestion, pain in the chest, cough, shortness of breath, broncho- and laryngospasm, respiratory distress syndrome.

From the skin: alopecia, rash, itchy skin, exacerbation of psoriasis, increased sweating, skin hyperemia, exanthema.

Laboratory indicators: agranulocytosis, leukopenia, thrombocytopenia, an increase in the activity of hepatic transaminases, LDH and bilirubin, hypoglycemia.

Influence on the fetus: intrauterine growth retardation, hypoglycemia, bradycardia.

Other: withdrawal syndrome, weakening of libido, impotence, Peyronie's disease, decreased thyroid function, arthralgia, allergic reactions, lupus syndrome, fever.

Overdose:

Symtomas: bradycardia, lowering blood pressure, dizziness (fainting), arrhythmias, difficulty breathing, cyanosis of the fingers or palms, convulsions.

Treatment: with severe bradycardia - intravenous atropine (1-2 mg dose), epinephrine, at low efficiency - pacemaker (temporarily); with ventricular extrasystole - lidocaine (preparations IA class do not apply); at an arterial hypotension and at absence of signs of a hypostasis of lungs - in / in introduction plazmozameshchajushchih solutions, at an inefficiency - epinephrine, dopamine, dobutamine; glucagon (has a pronounced positive inotropic and not so significant chronotropic action, independent of β-adrenergic receptors); with bronchospasm - inhalation or parenteral administration of β2-adrenomimetics and / or theophylline.

Interaction:

Abiraterone. It is recommended that caution be given abiraterone patients receiving propranolol (metabolized through the CYP2D6 system, has a narrow therapeutic index). In such cases, the possibility of reducing the dose of propranolol should be considered.

Agomelatine. Caution should be exercised when concomitant administration of agomelatine with propranolol (moderate inhibitor of the isoenzyme CYP1A2) before the accumulation of sufficient clinical experience.

Amiodarone. With the simultaneous use of amiodarone with propranolol, the risk of developing or worsening bradycardia, AV blockade, cardiac arrest and heart failure increases.

Amiodarone. Amiodarone (has a weak beta-blocking activity) increases the risk of excessive hypotension and bradycardia.

Articaine + Epinephrine. Simultaneous application of the combination articaine + epinephrine with propranolol contraindicated because of the risk of developing a hypertensive crisis and severe bradycardia.

Atracuria bezylate. Propranolol when combined with atrakury besylate strengthens the neuromuscular blockade and can enhance or unmask the latent myasthenia gravis or cause a myasthenic syndrome, which can lead to hypersensitivity to atracurium bezilate.

Acetylsalicylic acid. Acetylsalicylic acid weakens the hypotensive effect of propranolol (a consequence of inhibition of PG synthesis in the kidneys with a decrease in renal blood flow and sodium and liquid retention).

Belladonna Leaf Extract + Benzocaine + Metamizol sodium + Sodium bicarbonate. Combination effect belladonna leaves extract + benzocaine + metamizole sodium + sodium hydrogen carbonate strengthens propranolol (slows inactivation).

Belladonna Leaf Extract + Caffeine + Paracetamol + Theophylline + Phenobarbital + Cytisine + Ephedrine. Propranolol increases the concentration of theophylline (in combination Belladonna Leaf Extract + Caffeine + Paracetamol + Theophylline + Phenobarbital + Cytisine + Ephedrine) in the blood and therefore may increase the risk of developing its side effects.

Bendazole + Metamizol sodium + Papaverine + Phenobarbital. Combination with propranolol enhances the hypotensive effect of the combination Bendazole + metamizol sodium + papaverine + phenobarbital.

Benzathine benzylpenicillin. Increases the content of free fraction in the plasma, because, having a greater ability to bind to proteins, displaces from the fixation sites.

Betaxolol. Propranolol enhances (mutually) effects.Beta-blockers, administered orally, incl. propranolol, together with beta-adrenoblokatorami used in ophthalmology (eye drops), including. Betaxolol, increase the decrease in IOP; with the effects of systemic blockade of beta-adrenergic receptors, as a rule, increase.

Bisoprolol. Mutually enhances effects; combined use is contraindicated.

Bromhexine + Guaifenesin + Salbutamol. It is not recommended to use a combination bromhexine + guaifenesin + salbutamol concomitantly with propranolol.

Bromhexine + Guaifenesin + Salbutamol + Racetenthol. It is not recommended to use a combination bromhexine + guaifenesin + salbutamol + racemetol concomitantly with propranolol.

Bupivacaine + Epinephrine. When combined application propranolol - noncardioselective beta-blocker - enhances the pressor effect of epinephrine (in combination bupivacaine + epinephrine), which can lead to severe arterial hypertension and bradycardia.

Warfarin. Propranolol when combined, prolongs the anticoagulant effect of warfarin.

Warfarin. Propranolol increases the effect of warfarin.

Verapamil.Contraindications are simultaneous reception of propranolol and iv injection of verapamil.

Verapamil. Propranolol (mutually) effect and can increase the negative effect on heart rate, AV conduction and / or cardiac contractility, causing severe bradycardia, AV blockade (up to the full). Against the background of verapamil, the clearance decreases.

Hydralazine. The combined use of propranolol with hydralazine increases the risk of excessive blood pressure lowering.

Hydrochlorothiazide. Strengthens (mutually) antihypertensive effect.

Hydrochlorothiazide + Captopril. Combination hydrochlorothiazide + captopril increases the bioavailability of propranolol and enhances (mutually) the effects.

Glimepiride. Propranolol Increases (by 20%) Cmax, AUC and T1 / 2. Enhances the effect.

Glipizide. Propranolol strengthens the effect. When combined, dose adjustment may be required.

Glucagon. The introduction of glucagon against the background of propranolol can lead to severe tachycardia and increased blood pressure.

Guangfing. With the simultaneous use of guanfacin with propranolol, the risk of developing or worsening bradycardia, AV blockade, cardiac arrest and heart failure increases.

Dextromethorphan + Paracetamol + Pseudoephedrine + [Ascorbic acid]

Propranolol, when combined, can enhance the vasoconstrictive effect of pseudoephedrine (in combination dextromethorphan + paracetamol + pseudoephedrine + [ascorbic acid]).

Digoxin. Strengthens (mutually) the inhibition of AV conduction.

Diltiazem. Contraindicated simultaneous administration of propranolol and iv diltiazem administration.

Diltiazem. Enhances (mutually) negative chrono, foreign and dromotropic effects. Against the background of diltiazem bioavailability of propranolol increases.

Dobutamine. Reduces (mutually) cardiac effects. Against the background of dobutamine, an increase in OPSS is possible.

Dronedaron. In clinical studies using a combination of dronedarone with propranolol, bradycardia was more often observed.

It is recommended to use caution propranolol together with dronedarone because of pharmacokinetic and possible pharmacodynamic interaction (risk of summation of inhibitory effect on sinus and AV nodes). To start treatment with metoprolol it is necessary from low doses and to increase their dose only under the control of an electrocardiogram. Patients who are already receiving propranolol, the addition of dronedarone should be performed under ECG monitoring and, if necessary, adjust the dose of propranolol.

Indapamide. Strengthens (mutually) antihypertensive effect.

Interferon alfa. Joint use with interferon alpha as an injection solution can lead to a change in the metabolism of propranolol.

Interferon alfa-2b. Interferon alfa-2b is able to reduce the activity of cytochrome P450 and, therefore, interfere with the metabolism of propranolol.

Captopril. Propranolol strengthens (mutually) the hypotensive effect.

Clonidine. The combined use of propranolol with clonidine increases the risk of excessive blood pressure lowering.

Levotiroksin sodium. Reduces the activity of T4 5-deiodinase, although the levels of T3 and T4 changes slightly. Against the background of levothyroxine sodium (when hypothyroidism is converted into an euthyroid state), the effect may be weakened.

Lidocaine. Propranolol when combined, reduces the clearance of lidocaine and increases its concentration in the plasma.

Lidocaine. Propranolol reduces hepatic clearance of lidocaine (reduced metabolism due to inhibition of microsomal liver enzymes and decreased hepatic blood flow) and increases the risk of toxic effects.

Lidocaine + Chlorhexidine. Propranolol reduces hepatic clearance of lidocaine (in combination lidocaine + chlorhexidine in the form of a spray for topical application) - a decrease in metabolism due to inhibition of microsomal oxidation and a decrease in hepatic blood flow - and increases the risk of toxic effects (including stun, drowsiness, bradycardia, paresthesia, etc.).

Lorazepam. When combined application propranolol increases the level of lorazepam in plasma.

Maprotiline. Maprotiline is metabolized predominantly by the isoenzyme CYP2D6. The simultaneous use of maprotiline with beta-adrenoblocker propranolol, which is an inhibitor of the isoenzyme CYP2D6, may lead to an increase in the concentration of maprotiline in plasma. In such cases it is recommended to monitor the concentration of maprotiline in the plasma and, if necessary, adjust the dose.

Metamizol sodium. Propranolol slows biotransformation and increases the effect of metamizole sodium.

Metamizol sodium + Pitofenone + Fenpiverinia bromide. When combined propranolol (slows the inactivation of metamizol sodium) enhances the effect of the combination metamizol sodium + pitofenon + fenpiverinia bromide.

Metamizol sodium + Triacetonamino-4-toluenesulfonate. Propranolol slows the inactivation of metamizole sodium (in combination metamizol sodium+ triacetonamine-4-toluenesulfonate) and enhances its effect.

Metamizol sodium + quinine. Propranolol intensifies the combination metamizole sodium + quinine.

Methyldopa. With the simultaneous use of propranolol with methyldopa, the risk of developing or worsening bradycardia, AV blockade, cardiac arrest and heart failure is increased.

Methyldopa. Propranolol enhances (mutually) antihypertensive effect.

Mivakuriya chloride. Propranolol enhances the effect, incl. ability to unmask and increase the severity of myasthenia gravis.

Naproxen. On the background of naproxen, the antihypertensive effect of propranolol is weakened.

Naproxen + Esomeprazole. Naproxen (in combination naproxen + esomeprazole) can reduce the antihypertensive effect of propranolol.

Nitroglycerine. Strengthens (mutually) the hypotensive effect.

Nifedipine. The simultaneous use of propranolol and nifedipine can lead to a significant reduction in blood pressure.

Octreotide.Against the background of octreotide, the probability of developing severe bradycardia, arrhythmias and conduction disorders increases.

Pasireiform. It is recommended to monitor heart rate when administering pasireotid to patients receiving concomitant therapy propranolol, causing a bradycardia.

Pentaerythrityl tetranitrate. When combined application propranolol enhances the antianginal effect of pentaerythritol tetranitrate.

Pilocarpine. Against the background of systemic action of pilocarpine, the risk of conduction disruption increases.

Pyridostigmine bromide. When combined application propranolol weaken the effects of pyridostigmine bromide.

Piroxicam. Against the background of piroxicam, the hypotensive effect is weakened, although the concentration of the free fraction in the plasma increases (it is displaced from the connection with proteins).

Propaphenone. Against the background of propafenone (substrate CYP2D6) biotransformation is blocked, plasma concentration significantly increases, T1 / 2 is prolonged.

Propylthiouracil. Against the background of propylthiouracil, the effects change; a combined dose may require a correction of the dose of propranolol.

Reserpine.With simultaneous application of reserpine with propranolol increases the risk of developing or worsening bradycardia, AV blockade, cardiac arrest and heart failure.

Repaglinide. Propranolol increases hypoglycemic Effect; can camouflage some of the symptoms of hypoglycemia.

Risperidone. Strengthens (mutually) antihypertensive effect.

Rifampicin. Rifampicin when combined, shortens T1 / 2 propranolol.

Rifapentin. Rifapentin can increase metabolism and decrease the activity of propranolol; when used simultaneously with rifapentin, dosage correction of propranolol may be required.

Salmeterol. Propranolol weakens the effect; can cause bronchospasm in patients with asthma.

Simaldrat. Against the background of the simultaneous decrease in the absorption of propranolol; when combined appointment, the interval between admission should be at least 2 hours.

Sulfasalazine. Sulfasalazine when combined, increases the concentration of propranolol in plasma.

Terazosin. Propranolol strengthens (mutually) the hypotensive effect; with a combined appointment, a significant reduction in blood pressure, requiring lower doses, is possible.

Terbutaline. Propranolol weakens the effect and can cause bronchospasm in patients with asthma.

Thiamine. Thiamine when combined, decreases the pharmacological activity of propranolol.

Thioridazine. The combined use of propranolol (100-800 mg daily) and thioridazine causes an increase in plasma levels of thioridazine (approximately 50-400%) and its metabolites (approximately 80-300%); The combined use of propranolol and thioridazine should be avoided.

Trifluoperazine. With the simultaneous administration of trifluoperazine with propranolol, there is an increase in the concentration of both drugs.

Ubidekarenon. The simultaneous use of propranolol can lead to a decrease in the concentration of ubidecarenone in the blood plasma.

Felodipine. Felodipine increases the bioavailability of propranolol; when combined propranolol enhances the hypotensive effect of felodipine.

Phenylephrine. Propranolol can unpredictably increase the hypertensive effect (in one of the reports it was reported about a sharp rise in blood pressure).

Phenytoin. The combined use of propranolol with phenytoin increases the severity of cardiodepressive action and the risk of lowering blood pressure.

Fluvoxamine. Fluvoxamine when combined, increases the concentration of propranolol in the blood plasma.

Fluvoxamine. On the background of fluvoxamine, the plasma level of propranolol rises (5-fold).

Fosinopril. With simultaneous application propranolol enhances the hypotensive effect of fosinopril. Bioavailability of fosinopril with simultaneous application with propranolol does not change.

Cimetidine. Cimetidine when combined, increases the concentration of propranolol in plasma.

Cisatracurium bezylate. When combined application propranolol enhances the effect of cisatracurium bezilate. In rare cases propranolol may worsen the course or contribute to the manifestation of a latent myasthenia gravis, and also cause a myasthenic syndrome; as a result, there may be increased sensitivity to cisatracurium bezylate.

Ethanol. The combined use of propranolol with ethanol increases the risk of CNS depression.

Special instructions:

Non-selective β-adrenoblocker without internal sympathomimetic activity; has a pronounced quinidine-like (membrane-stabilizing) effect.

One of the most studied β-adrenoblockers with proven efficacy of A level in IHD (angina pectoris,myocardial infarction) and AGA4; reduces the risk of repeated infarction and fatal outcome in patients with cardiovascular pathology.

As a lipophilic β-adrenoceptor, propranolol causes more pronounced side effects on the part of the CNS (restless, anxious sleep, an increase in the duration and number of episodes of night wakefulness) compared with the hydrophilic β1-adrenoblocker-atenolol.

In patients with hypertension taking propranolol in a dose of 80-400 mg / day, cases of depression and sexual dysfunction have not been reported.

During the treatment, it is possible to change the test results when carrying out laboratory tests (increased levels of urea, transaminases, phosphatases, LDH).

Treatment should be carried out with regular medical supervision.

With prolonged use, the possibility of an additional appointment of cardiac glycosides should be considered. Reduces compensatory cardiovascular reactions in response to the use of general anesthetics. A few days before the anesthesia should stop taking or choose an anesthetic with the least negative inotropic effect.

Intravenous introduction to children is not recommended.

In elderly patients, the risk of CNS side effects is increased.

If the liver function is impaired, it is recommended to reduce doses and observe in the first 4 days of therapy.

Can mask symptoms of hypoglycemia (tachycardia) in diabetic patients taking insulin and other hypoglycemic drugs.

It is possible to increase the severity of the hypersensitivity reaction and the lack of effect from the usual doses of epinephrine against the background of a burdened allergic anamnesis. At the time of treatment, it is recommended to exclude the use of alcoholic beverages.

Impact on the ability to drive vehicles and manage mechanisms.

With caution apply during work drivers of vehicles and people whose profession is associated with increased concentration of attention. Stop treatment gradually, for about 2 weeks.

Instructions

Propranolol (Propranololum)