Safety recommendation
It is recommended that the National Institute for Health and Care Excellence reviews and updates guidance on the use of propranolol in the treatment of anxiety and migraine, with particular reference to the toxicity of propranolol in overdose.
Response:
NICE does not recommend the use of propranolol in anxiety. It assumes that organisations which do recommend its use in this indication will be asked to review and update any guidance.
NICE would also like to point out that, while the emphasis of the report is on the harmful effects of propranolol in overdose, it is important that the potential harm from other beta-blockers is not neglected: other beta-blockers are sometimes used for migraine prophylaxis (see British Association for the Study of Headache [BASH] guidelines 2010). Finally, this report is about the potential under-recognised risk of harm from propranolol in overdose, not in usual therapeutic use.
NICE will add a footnote to headache guidance (CG150) that propranolol and topiramate may worsen or cause depression, noting that people with migraine often also have depression, and advising caution when using these medicines in people with depression and referring to toxicity of propranolol in overdose.
The guidance on generalised anxiety disorder and social anxiety disorder does not recommend propranolol for this indication. There is no recommendation in the BNF to use propranolol for the treatment of anxiety in isolation.
The BNF does provide dose information for the treatment of anxiety with symptoms such as palpitation, sweating and tremor, reflecting the licensed dose for these indications. The BNF includes information on overdose of propranolol. NICE holds the contract to provide the BNF to the NHS and we will discuss this issue with them.
Response received on 18 February 2020.