Propranalol - Higher Bp And More Tachy When It'S Worn Off

[issie]

I've been recently trying propranlol. I knew when I started that it had the potential to lower renin (all beta blockers can). But, I felt like it was worth a try to see if it would help my high heart rates and tachy upon standing. It has helped those things - except, when it has worn off. My blood pressure is higher than it's ever been before and the tachy is pretty intense. This is a short acting med and it seems that it is causing the issue to be worse than it was - when it wears off. Since it will lower renin, I'm wondering if this rebound effect is maybe worse than not using it in the first place. I don't want to have "eternal" issues due to a drug causing my body to be worse in the long run. We tend to have low renin and aldesterone anyway - lowering it more (BIG QUESTION MARK??????) One thing for sure, I'm more dehydrated taking it. I'm thinking even though it's helping somewhat - maybe in the long run it's not the best thing to do. Any one else out there experienced this?

Issie

[sj75]

My understanding is that all beta blockers have a rebound effect which is why you arent supposed to stop them suddenly. They build up in the system in order to reach their optimim levels. They suppress the release of? adrenaline and when stopped suddenly you get larger surges of it hence an increase in bp and hr.x

[MontanaKimberly]

I would recommend trying a longer acting betablocker (or an extended release) version.

[TXPOTS]

The immediate release is dosed two to four times daily.

The long acting is dosed once a day.

If you are on the immediate release, it is not meant to be taken once a day, unless it is being used on an as needed basis for stage fright/ anxiety.

[issie]

But, why would it make the bp higher than it's EVER in my life been? I don't know if I want to make things worse in the long run. I did a search on the site and someone else said the same thing had happened with this drug and they felt like it had messed them up worse.

[firewatcher]

Propranolol has been a wonder drug for me. I have upright hypertension, tachycardia and tremors and it has been the only thing to help all those. I also have supine bradycardia (low 40's BPM) so my docs decided that once daily was enough for me, and only before noon. 20mg tends to last for about twelve hours in my body and evenings/nights are not a big deal for me: I'm not as super-tachy as in the mornings.

[TXPOTS]

Issie,

The higher bp could be rebound when the drug has worn off (hence the recommendation for UP TO 3-4x daily dosing) or less likely, beta 2 antagonism. It is a non-selective agent.

I would ask the prescribing doctor. It wouldn't be dosed four times daily in some patients with POTS if the twice daily dosing worked for everyone. So, you may be one of those patients needing more frequent dosing due to the way YOU metabolize the drug and the low dose. You have to decide how you feel on the drug and tailor a dose and schedule that works for YOU. Patients with POTS seem to have odd reactions to drugs that the non-dysautonomic population does not experience. You should keep working with your doctor on finding the right dose or decide it's not right for you. I would explain what is happening to your doctor and see what he/ she advises. Certainly, if your renin and aldosterone are low to begin with this is something to keep in mind since beta blockers do lower renin.

On a personal note, I sampled propranolol, and it made me feel worse. I was glad that I tried and ruled out another option. Initially, I thought I could not tolerate Florinef, but it just took time to mess around with the dose and timing.

Have you taken your heart rate and bp 60-90 minutes after taking propranolol? This is when the drug should be at peak effect.

Firewatcher,

Glad you have found success with propranolol and a dose that works for you. It can be a wonder for certain kinds of tremors and certain kinds of anxiety. I'll be sending you my revised article this week. The last week has brought lots of excellent beta blocker questions on the forum.

[Guest tearose]

You raise an extremely important question.

I think this is the essential reason why treating ANS issues is so difficult.

Many can and do become tolerant of a drug and then need more of it or must come off of it or can even become "sensitive" to it.

May I suggest you have this conversation with a knowledgeable doctor so you can make an informed choice as how to tweak your your treatment plan.

[Ashelton80]

I took propranolol for a week and it made my bp higher than normal as well. I don't think it was when it was worn off though. I chopped it up to the fact that since it was keeping my heartrate from being elevated then my body had to manage and keep me upright somehow, so it would raise bp. This is probably a good thing for some, but for me it made me feel worse. I have POTS and I can walk around for the most part without feeling like I'm going to pass out. When I was on propranolol I felt like I would pass out and vomit at the same time. My heartrate was nice and low and my chest pain was gone though. :/ I lasted a week on it before deciding it wasn't for me.

[TXPOTS]

I took propranolol for a week and it made my bp higher than normal as well. I don't think it was when it was worn off though. I chopped it up to the fact that since it was keeping my heartrate from being elevated then my body had to manage and keep me upright somehow, so it would raise bp. This is probably a good thing for some, but for me it made me feel worse. I have POTS and I can walk around for the most part without feeling like I'm going to pass out. When I was on propranolol I felt like I would pass out and vomit at the same time. My heartrate was nice and low and my chest pain was gone though. :/ I lasted a week on it before deciding it wasn't for me.

If the heart rate is low and the blood pressure is high on propranolol, it could be from unopposed alpha receptor stimulation or beta 2 antagonism from a non-selective beta blocker. For example in pheochromocytoma (a high adrenaline state from a tumor), pure beta blockers are contraindicated due to unopposed alpha stimulation. Alpha receptors on blood vessels cause constriction when stimulated. POTS patients can often produce high levels of adrenaline. It's interesting, but I notice Dr. Grubb mentions using Labaetalol or Coreg in hyperadrenergic POTS patients. He doesn't specifically mention other beta blockers in his review article. These are mixed beta/ alpha agonists. Even patients not on any medication may when heart rate is lower, blood pressure is higher.

[firewatcher]

I took propranolol for a week and it made my bp higher than normal as well. I don't think it was when it was worn off though. I chopped it up to the fact that since it was keeping my heartrate from being elevated then my body had to manage and keep me upright somehow, so it would raise bp. This is probably a good thing for some, but for me it made me feel worse. I have POTS and I can walk around for the most part without feeling like I'm going to pass out. When I was on propranolol I felt like I would pass out and vomit at the same time. My heartrate was nice and low and my chest pain was gone though. :/ I lasted a week on it before deciding it wasn't for me.

If the heart rate is low and the blood pressure is high on propranolol, it could be from unopposed alpha receptor stimulation or beta 2 antagonism from a non-selective beta blocker. For example in pheochromocytoma (a high adrenaline state from a tumor), pure beta blockers are contraindicated due to unopposed alpha stimulation. Alpha receptors on blood vessels cause constriction when stimulated. POTS patients can often produce high levels of adrenaline. It's interesting, but I notice Dr. Grubb mentions using Labaetalol or Coreg in hyperadrenergic POTS patients. He doesn't specifically mention other beta blockers in his review article. These are mixed beta/ alpha agonists. Even patients not on any medication may when heart rate is lower, blood pressure is higher.

Gggrrrrrrrrrrrrr.......

I went through a cardiology fiasco for something like this six months ago! I was suddenly developing bradycardia (42-50 BPM) and chest pain with hypertension when upright. I finally thought I had narrowed it down to high serum osmolality since it only happened when my dDAVP wore off. Any of the three cardiologists I've seen should have thought of unopposed adrenaline/alpha stimulation...they all told me to ignore it: "Chest pain is common in POTS patients..." I see the cardiologist in a week; guess what I'll be asking him!

[TXPOTS]

I would think this would only be a concern in central hyperadrenergic patients (upright NE > 1000 pg/ml), as opposed to the peripheral denervation variety (if we follow these classifications). Even the Vandy review article stress the importance of regulating NE centrally and peripherally, which is why clonidine or even methyldopa are popular choices (or even Labetalol and Coreg). I guess the only way to know is to try various medication combos under the watchful eyes of a responsible physician willing to work with us when the non-pharmacologic stuff fails. Dr. Grubb and Vandy do seem to be treating hyperadrenergic patients with different med combos than the more common variety of PD POTS.

[issie]

I looked up clonidine it seems to have the same qualities as the propranalol but it to warns of a rebound effect too. Since I have only been on 5mg of propranalol one to two times a day. I don't know why it's had such an effect. I know that I'm super sensitive to meds. I think for now, I'll stay off of it until I see the neuro at the end of next week. He would probably want me off of it any way to do his testing. I really liked that it had helped the tachy and chest/heart pains but sure didn't like my bp being so high upon standing when it was starting to wear off. Thanks for all the input - I appreciate your insights!!

Issie

[TXPOTS]

I looked up clonidine it seems to have the same qualities as the propranalol but it to warns of a rebound effect too. Since I have only been on 5mg of propranalol one to two times a day. I don't know why it's had such an effect. I know that I'm super sensitive to meds. I think for now, I'll stay off of it until I see the neuro at the end of next week. He would probably want me off of it any way to do his testing. I really liked that it had helped the tachy and chest/heart pains but sure didn't like my bp being so high upon standing when it was starting to wear off. Thanks for all the input - I appreciate your insights!!

Issie

Well, not the same qualities, but along similar lines. Clonidine is an alpha 2 agonist. It blocks the release of catecholamines from the brain stem, whereas propranolol blocks some of the receptor sites (beta 1 and beta 2). Clonidine works further up the chain of the events and only recommended for hyperadrenergic patients in the literature. Sometimes the increase in sympathetic tone is compensatory in POTS, so blocking adrenaline release or action at receptor sites may be counter productive. It depends on the mechanism causing POTS. With EDS, blood vessels may be more floppy, so the increase in sympathetic tone may be necessary to maintain perfusion upstairs. Good luck with the neuro visit, Issie. I hope your physicians can can up with a plan that gets rid of the tachy and chest pain without the high blood pressure. I'm super sensitive to meds as well. It's frustrating!

[issie]

Well, not the same qualities, but along similar lines. Clonidine is an alpha 2 agonist. It blocks the release of catecholamines from the brain stem, whereas propranolol blocks some of the receptor sites (beta 1 and beta 2). Clonidine works further up the chain of the events and only recommended for hyperadrenergic patients in the literature. Sometimes the increase in sympathetic tone is compensatory in POTS, so blocking adrenaline release or action at receptor sites may be counter productive. It depends on the mechanism causing POTS. With EDS, blood vessels may be more floppy, so the increase in sympathetic tone may be necessary to maintain perfusion upstairs. Good luck with the neuro visit, Issie. I hope your physicians can can up with a plan that gets rid of the tachy and chest pain without the high blood pressure. I'm super sensitive to meds as well. It's frustrating!

Okay, so taking a beta blocker for a person who has EDS and poor vascular support anyway, would make matters worse. Am I understanding you correctly? I looked up how to increase in sympathetic tone to maintain perfusion and came up with the need of a release of noriepi in persons who are in congestive heart failure. If you lower the nori then you compound the problem of CHF. It may be that the release of too much nori in some of us is what's keeping us out of heart failure. (If I'm understanding what I just read.) It also showed the need of IV's to increase fluid in the veins - something about needing a thicker solution for the veins to be able to hold the fluid. One place told what type of solution to use and how to slowly administer it. (I think before this is all figured out - I should have a MD after my name. Ha!Ha!)

[Ashelton80]

I took propranolol for a week and it made my bp higher than normal as well. I don't think it was when it was worn off though. I chopped it up to the fact that since it was keeping my heartrate from being elevated then my body had to manage and keep me upright somehow, so it would raise bp. This is probably a good thing for some, but for me it made me feel worse. I have POTS and I can walk around for the most part without feeling like I'm going to pass out. When I was on propranolol I felt like I would pass out and vomit at the same time. My heartrate was nice and low and my chest pain was gone though. :/ I lasted a week on it before deciding it wasn't for me.

If the heart rate is low and the blood pressure is high on propranolol, it could be from unopposed alpha receptor stimulation or beta 2 antagonism from a non-selective beta blocker. For example in pheochromocytoma (a high adrenaline state from a tumor), pure beta blockers are contraindicated due to unopposed alpha stimulation. Alpha receptors on blood vessels cause constriction when stimulated. POTS patients can often produce high levels of adrenaline. It's interesting, but I notice Dr. Grubb mentions using Labaetalol or Coreg in hyperadrenergic POTS patients. He doesn't specifically mention other beta blockers in his review article. These are mixed beta/ alpha agonists. Even patients not on any medication may when heart rate is lower, blood pressure is higher.

So, should I try a selective beta blocker? Would that do anything different ? This is all a little over my head. . Are u saying the extra constriction is counterproductive for me. I'm not sure if I am hyperadrenergic, but feel as though I might be. I have often told my husband that it feels like I have too much adrenaline release. Thanks for your response!

[momdi]

Michael did much better when the doc switched him from inderal to toprol xl and added clonidine. Even though the toprol is a once daily dose, he splits the dose and takes it twice daily. He did the toprol xl first and got accustomed to that and then worked in the clonidine. The clonidine is what finally improved his sleep patterns, allowing to actually get to sleep at night and be awake during the day.

Good luck!

[TXPOTS]

Ashelton,

If you are starting Dr. Levine's protocol, the beta blockers are not allowed to do the study. Only a physician with POTS knowledge can determine whether you are hyperadrenergic. Many POTS patients have higher levels of upright adrenaline, but it does not always mean they fit into the hyperadrenergic category according to the Vanderbilt review.

Issie,

I once had an infusion of albumin and saline to hold the fluid in my vessels longer. It made me feel much better at the time. I have little knowledge of intricacies of CHF and EDS. I only know the mechanisms of the drugs and the POTS research and review articles pertaining to medications. Sometimes drugs that seem counterproductive actually help patients. Also, drugs in various combinations help people. One drug may be a vasoconstrictor and another a beta blocker. Only a physician has the patient experience with prescribing and dosing, and only you know whether a medication is making a difference in the way you feel.

[Ashelton80]

Ashelton,

If you are starting Dr. Levine's protocol, the beta blockers are not allowed to do the study. Only a physician with POTS knowledge can determine whether you are hyperadrenergic. Many POTS patients have higher levels of upright adrenaline, but it does not always mean they fit into the hyperadrenergic category according to the Vanderbilt review.

Issie,

I once had an infusion of albumin and saline to hold the fluid in my vessels longer. It made me feel much better at the time. I have little knowledge of intricacies of CHF and EDS. I only know the mechanisms of the drugs and the POTS research and review articles pertaining to medications. Sometimes drugs that seem counterproductive actually help patients. Also, drugs in various combinations help people. One drug may be a vasoconstrictor and another a beta blocker. Only a physician has the patient experience with prescribing and dosing, and only you know whether a medication is making a difference in the way you feel.

Oh yes I know I can't have it during the protocol. I guess I'm just always thinking ahead with the what ifs. What if I can't complete the protocol, what if it just makes me worse, what if it just doesn't work for me. Ugh. I know that's not good, but it seems everything I have tried has been futile so I just expect things not to work out in my favor now. . Thanks for the info

[TXPOTS]

Ashleton,

Very best of luck on the exercise protocol. Exercise has done wonders for me. I was on a graded exercise protocol and now can run 6 miles/ day.

If you ever needed to explore more options, I wouldn't worry about excessive constriction from a non-selective beta blocker or unopposed alpha stimulation in high adrenaline states. Most POTS patients who can not tolerate beta blockers find their blood pressure becomes too low when standing, and they become fatigued and dizzy. These were just ideas why beta blockers could cause high blood pressure in a very small subset of patients.

[issie]

[quote name='TXPOTS' timestamp='1287367963' post='147571'

I wouldn't worry about excessive constriction from a non-selective beta blocker or unopposed alpha stimulation in high adrenaline states. Most POTS patients who can not tolerate beta blockers find their blood pressure becomes too low when standing, and they become fatigued and dizzy. These were just ideas why beta blockers could cause high blood pressure in a very small subset of patients.

When I tried Toporol and Bystolic that's what happened to me. I had a hard time trying to keep my bp high enough. I would have to walk around to get it up and do pressure exercises to try to increase my bp. That's why, I'm so surprised with the reaction to propranalol and high bp with wear off. Any way, I've been off it for a week now and no more real high bp. I'm feeling better not using it, as to how I felt when it wore off. It also kept me from restful sleep if I took a second dose in the p.m. So, don't think that will work for me.

[TXPOTS]

\

Insomnia can be a problem with beta blockers. I'm sorry that it didn't work out, Issie.