Rectal propranolol controls paroxysmal sympathetic hyperactivity: a case report

Pharmacotherapy. 2015 Apr;35(4):e27-31. doi: 10.1002/phar.1568.


Paroxysmal sympathetic hyperactivity (PSH) affects approximately 10% of survivors of acquired brain injury and is associated with substantial morbidity. The most effective maintenance therapies include oral β-blockers and α-2 antagonists. We report the use of rectal propranolol for symptomatic control of PSH in a critically ill patient with an altered gastrointestinal tract for whom oral intake was contraindicated. A 15-year-old Caucasian male with no past medical history was admitted status post all-terrain vehicle rollover with multiple intra-abdominal injuries. On hospital day 40, the patient experienced cardiac arrest with a subsequent anoxic brain injury, which was complicated by the development of PSH on post-arrest day 1. Because of his altered gastrointestinal tract, he was symptomatically managed with propranolol 40 mg per rectum every 6 hours in the form of specially prepared suppositories, intravenously infused morphine and dexmedetomidine, and a transdermal clonidine patch. The patient improved clinically during this treatment and was transferred to a rehabilitation facility. This is the first case report to describe successful use of propranolol suppositories in a clinical environment. This case supports the use of propranolol suppositories as a potential alternative route when oral administration is not possible.

Keywords: paroxysmal sympathetic hyperactivity; pharmacokinetics; rectal propranolol.

Publication types

  • Case Reports

MeSH terms

  • Abdominal Injuries / drug therapy*
  • Abdominal Injuries / physiopathology
  • Administration, Rectal
  • Adolescent
  • Adrenergic beta-Antagonists / administration & dosage*
  • Autonomic Nervous System Diseases / drug therapy*
  • Autonomic Nervous System Diseases / physiopathology
  • Gastrointestinal Tract / drug effects*
  • Gastrointestinal Tract / injuries
  • Gastrointestinal Tract / physiopathology
  • Humans
  • Male
  • Propranolol / administration & dosage*
  • Wounds, Nonpenetrating / drug therapy*
  • Wounds, Nonpenetrating / physiopathology


  • Adrenergic beta-Antagonists
  • Propranolol