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Key takeaways
Propranolol is a beta blocker used for migraines, tremors, anxiety, hypertension, and atrial fibrillation. Due to its potential for side effects, some individuals may seek alternatives.
Alternatives to propranolol within the beta blocker class or other medication classes depend on the specific condition being treated, such as Inderal LA for hypertension and Nurtec for migraine prevention.
The top common alternatives to propranolol include Inderal LA, Toprol XL, Coreg, Cardizem CD, and Nurtec, each offering different benefits and side effects compared to propranolol.
Natural alternatives and lifestyle changes, such as a low-salt diet, exercise, and supplements like coenzyme Q10 and magnesium, can also serve as adjuncts or alternatives for conditions treated by propranolol.
Propranolol is the granddaddy of the beta-blocker family of medications. First approved by the Food and Drug Administration (FDA) over 50 years ago under the brand name Inderal, it has accumulated a diverse list of uses. Propranolol can be taken for neurologic conditions like migraines, tremors, or anxiety or a cardiac condition like hypertension or atrial fibrillation. Propranolol’s broad use puts it on the World Health Organization’s essential medication list. That honor and its long history do not necessarily mean that it is the best option because taking propranolol certainly has some drawbacks in the form of side effects. We will lay out other options here so that a meaningful conversation with a healthcare provider can occur.
What can I take in place of propranolol?
The first stop in the search for potential propranolol replacements does not even require leaving the beta-blocker family. Depending on the circumstance, there may be compelling reasons for simply changing to a different drug within the class. Differences in beta receptor activity and the addition of alpha receptor action comprise the nuances of picking a proper beta-blocker.
If moving away from the drug class makes the most sense, then the best alternative will depend on what indication propranolol is being taken for. Options for migraine prevention are quite different from options for atrial fibrillation. With that said, let’s delve into the details to offer a better understanding of the available alternatives..
Compare propranolol Hcl (Inderal) alternatives |
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|---|---|---|---|
| Drug name | Uses | Dosage | Savings options |
| Propranolol | Hypertension, atrial fibrillation, angina (chest pain), cardiovascular event risk reduction after heart attack, migraine prophylaxis, essential tremor, performance anxiety (off-label) | 80-320 mg daily divided into two to four doses for hypertension | Propranolol coupons |
| Inderal LA (long-acting propranolol) | Hypertension, angina, migraine prophylaxis, idiopathic hypertrophic subaortic stenosis | 80-160 mg once daily for hypertension | Inderal LA coupons |
| Bystolic (nebivolol) | Hypertension | 2.5 to 40 mg once daily | Bystolic coupons |
| Coreg (carvedilol) | Hypertension, congestive heart failure (CHF) with low ejection fraction (EF or heart squeeze), left ventricular dysfunction after MI | 3.125 to 25 mg twice daily | Coreg coupons |
| Toprol XL (metoprolol extended-release) | Hypertension, angina, CHF with low EF, migraine prevention (off-label) | 25 to 400 mg once daily | Toprol XL coupons |
| Zestril (lisinopril) | Hypertension, CHF with low EF, acute MI, migraine prevention (off-label) | 2.5 to 40 mg once daily | Zestril coupons |
| Hydrochlorothiazide (HCTZ) | Hypertension, peripheral edema (swelling) | 12.5 to 50 mg once daily (higher doses up to 200 mg may used for edema) | Hydrochlorothiazide coupons |
| Diovan (valsartan) | Hypertension, CHF with low EF, left ventricular dysfunction (reduced heart squeeze) after MI | 80 to 320 mg once daily (or daily dose divided into two doses) | Diovan coupons |
| Norvasc (amlodipine) | Hypertension, coronary artery disease (CAD) | 2.5 to 10 mg once daily | Norvasc coupons |
| Cardizem CD (diltiazem extended-release) | Hypertension, angina, ventricular rate control in atrial fibrillation (off-label) | 120 to 480 mg once daily | Cardizem CD coupons |
| Verapamil | Ventricular rate control in atrial fibrillation or atrial flutter | 80 to 120 mg three to four times daily | Verapamil coupons |
| Lanoxin (digoxin) | Ventricular rate control in atrial fibrillation or atrial flutter | 0.125 to 0.25 mg once daily | Lanoxin coupons |
| Nurtec (rimegepant) | Migraine headache prophylaxis, acute migraine headache | 75 mg as needed or every other day for prevention | Nurtec details |
| Qulipta (agogepant) | Migraine headache prophylaxis, acute migraine headache | 10 to 60 mg as needed daily for prevention | Qulipta coupons |
| Mysoline (primidone) | Essential tremor (off-label), seizure | 50-250 mg once daily at bedtime | Mysoline coupons |
Other alternatives to propranolol
- Lotensin (benazepril)
- Zestoretic (combination lisinopril/hydrochlorothiazide)
- Cozaar (losartan)
- Avapro (irbesartan)
- Lotrel (combination amlodipine/benazepril)
- Tenormin (atenolol)
- Lopressor (metoprolol)
- Bisoprolol
- Coreg CR (extended-release carvedilol)
- Trandate (labetalol)
- Ziac (bisoprolol/HCTZ)
- Tenoretic (atenolol/HCTZ)
- Altace (ramipril)
- Accupril (quinapril)
- Fosinopril
- Captopril
- Perindopril
- Benicar (olmesartan)
- Micardis (telmisartan)
- Atacand (candesartan)
- Tekturna (aliskiren)
- Chlorthalidone
- Calan SR (extended-release verapamil)
- Nifedical XL (extended-release nifedipine)
- Felodipine XR
- Isradipine
- Lotensin HCT (HCTZ/benazepril)
- Capozide (HCTZ/captopril)
- Vaseretic (HCTZ/enalapril)
- Accuretic (HCTZ/quinapril)
- HCTZ/fosinopril
- Exforge (amlodipine/valsartan)
- Azor (amlodipine/olmesartan)
- Twynsta (amlodipine/telmisartan)
- Benicar HCT (HCTZ/olmesartan)
- Hyzaar (HCTZ/losartan)
- Diovan HCT (HCTZ/valsartan)
- Micardis HCT (HCTZ/telmisartan)
- Avalide (HCTZ/irbesartan)
- Atacand (HCTZ/candesartan)
- Tekturna HCT (HCTZ/aliskiren)
- Tribenzor (amlodipine/HCTZ/olmesartan)
- Exforge HCT (amlodipine/HCTZ/valsartan)
- Catapres (clonidine)
- Catapres TTS (clonidine patch)
- Methyldopa
- Terazosin
- Lasix (furosemide)
- Aimovig (erenumab)
- Ajovy (fremanezumab)
- Emgality (galcanezumab)
- Topamax (topiramate)
- Trokendi XR (topiramate extended-release)
- Depakote (divalproex sodium)
- Depakote ER (divalproex extended-release)
Top 5 propranolol alternatives
The following are some of the most common alternatives to propranolol.
1. Inderal LA
Convenience is not a trivial matter when it comes to drug dosing. The more times we take a med each day, the more chances we have to forget it. Propranolol is a short-acting drug, having a duration of action of only six to 12 hours. That characteristic is beneficial if it is being taken to prevent physical symptoms of anxiety, like shakiness, before a speech, in which case, the need for the effects of propranolol to last long is unnecessary. On the other hand, if it is being taken for blood pressure control in hypertension or heart rate control in atrial fibrillation, the long-acting version may make more sense, Inderal LA, with a 24-hour duration of action. That duration means longer adverse effects, like bradycardia (slow heart rate), low blood pressure (hypotension), or an inability to sense low blood sugar levels may occur.
2. Toprol XL
Within the beta-blocker drug class, propranolol resides within the non-selective subdivision, meaning it blocks both beta-1 and beta-2 receptors. The blockade of beta-1 adrenoreceptors curtails the effect of adrenaline (natural epinephrine) and noradrenaline on our heart, meaning a slower heart rate and softer heartbeat. Meanwhile, beta-2 receptor inhibition results in smooth muscle tightening, which can tighten bronchial tubes and reduce portal venous blood flow in the abdomen.
Those beta-2 receptor effects are a mixed bag. A reduction in portal venous circulation can be desirable in cirrhosis of the liver, in which high portal venous blood pressure is a problem. To get off propranolol, another non-selective beta blocker, like Corgard, could be chosen. Changing to a different non-selective agent could also make sense if it is needed to treat a heart rhythm disturbance like atrial fibrillation. Betapace has a particular utility as an antiarrhythmic to help with arrhythmia (irregular heartbeat).
However, if wheezing from bronchial tube spasms is an issue, as it is in asthma, change to a selective beta-blocker with beta-1. Still, no significant beta-2 receptor activity may be more effective. Toprol XL is a popular alternative with more selective beta-blocking ways and a once-daily dosing feature.
3. Coreg
A few non-selective members of the drug class sprinkle in some alpha receptor antagonism, and blocking alpha receptors leads to vasodilation of arterial blood vessels. Relaxed arteries mean lower blood pressure, so if more antihypertensive effects than propranolol can provide are needed, changing to a dual beta and alpha-blocker might make sense. A common pick for this reason is Coreg.
4. Cardizem CD
None of the beta blockers are the first choice for high blood pressure management. Angiotensin-converting enzyme inhibitors, such as Zestril; angiotensin receptor blockers, like Diovan; thiazide diuretics; and dihydropyridine calcium channel blockers, such as Norvasc are all more favorable picks for hypertension for most people.
Exceptions would be those who could also benefit from beta-blockade for heart disease, including anyone who needs heart rate control for atrial fibrillation or angina prevention in coronary artery disease. Suppose propranolol or other beta blockers are ineffective or problematic due to common side effects. In that case, Cardizem CD is a non-dihydropyridine calcium channel blocker that has many of the same potential benefits by reducing both heart rate and blood pressure.
5. Nurtec
Besides cardiac and blood pressure uses, propranolol’s other niche is migraine prevention. Until recent years, the alternatives to beta blockers for reducing migraine frequency amounted to anti-epileptic pills, like Topamax and Depakote, or off-label use of antidepressant drugs, such as amitriptyline. Calcitonin gene-related peptide (CGRP) inhibitors have added a new angle to approaching migraine treatment. Nurtec has FDA indications for acute migraine relief and preventing this headache variety.
As a new agent, Nurtec is only available as a brand-name product, making it considerably more expensive than propranolol. If assistance is needed with the expense of medication, get a SingleCare discount card to present to a pharmacist.
Natural alternatives to propranolol
For each of propranolol’s uses, non-pharmacological treatment options may be an alternative route. A low-salt diet, exercise, and weight loss can assist hypertension management. Likewise, a routine of sleep, exercise, and meals may be helpful for migraine prevention.
Besides lifestyle measures, over-the-counter supplements are another available approach to limit the need for medications. In studies, potatoes, magnesium, fish oil, fiber, protein, and folate have had little success in reducing blood pressure. Small-scale clinical trials have also noted improved migraine frequency with coenzyme Q10, riboflavin, and magnesium. If propranolol is used for an anxiety disorder, the Mayo Clinic has reviewed herbal options. Remember that none of these alternatives has been well studied, and none should be substituted for a prescribed medication without discussing it fully with the prescribing healthcare provider.
How to switch to a propranolol alternative
Getting the medical advice of a healthcare professional prescribing propranolol is the next step in switching to a propranolol alternative. Sharing concerns about the drug and thoughts on other options is essential. The doctor will review medical history and any health conditions, a list of prescription drugs, and the different over-the-counter pills taken. Ultimately, one should be able to leave the appointment with an understanding of either why propranolol is the right choice or which alternative is better.
