Epinephrine and Atenolol: Interaction Details
AI-assisted, pharmacist-reviewed · AI content regenerated Jul 15, 2026 · Source data updated Jul 11, 2026 · Sources: FDA labeling, DDInter 2.0, cited literature
Atenolol
Epinephrine
No brand names on record
How we grade severity & evidence
Severity levels
- Contraindicated: These should generally not be used together.
- Major: Potentially serious — often needs a change or close monitoring.
- Moderate: Can be significant — usually manageable with monitoring.
- Minor: Usually limited clinical impact.
Evidence grades
- Established: Well documented — supported by controlled studies or strong clinical data.
- Probable: Good supporting evidence, though not definitively proven.
- Suspected: Some evidence suggests this interaction, but it is not well established.
- Possible: Limited or conflicting evidence; the interaction may occur.
- Theoretical: Predicted from the drugs' pharmacology; not yet confirmed in people.
Ratings come from the documented interaction literature and are reviewed by a pharmacist. They describe the documented risk of the combination, not what will necessarily happen to you — your dose, timing, and health picture all matter.
Atenolol (Tenormin) is a beta-blocker that slows your heart and lowers blood pressure. Epinephrine (adrenaline) does the opposite: it speeds the heart and opens the airways. When you take them together, they can clash in a way that causes problems.
Because the beta-blocker blocks part of epinephrine's action, the leftover effect can push your blood pressure very high and, oddly, make your heart beat too slowly. It can also trigger irregular heartbeats. This is considered a serious combination, but the good news is your care team can manage it by watching your blood pressure and heart rate closely. Never stop either medicine on your own, just talk with your doctor or pharmacist.
Effect: Concurrent atenolol (a beta-1 selective blocker) and epinephrine can produce unopposed alpha-adrenergic stimulation, leading to severe hypertension and reflex bradycardia with possible heart block. Beta-blockade also antagonizes epinephrine's cardiostimulatory and bronchodilator effects.
- Direction: Beta-blocker blunts epinephrine's beta effects; unopposed alpha vasoconstriction predominates.
- Severity/Evidence: Major; probable substantiation. Mechanism per file is unknown but consistent with alpha/beta imbalance.
- Onset: Unspecified.
- Management: Avoid coadministration where possible. If necessary, monitor BP and HR closely; observe for angina, ventricular arrhythmias, and conduction abnormalities.
Neither agent is a prodrug; interpretation is pharmacodynamic.
What happens
An increased risk of cardiac arrhythmias, an antagonized cardio stimulating and bronchodilation effects of EPINEPHrine, an increased risk of severe hypertension and an increased risk of bradycardia
Interaction Deep Dive
Concurrent use of EPINEPHrine with beta-blocker and antiarrhythmic drugs should be avoided, since the combination can result in severe hypertension along with bradycardia and possible heart block. When simultaneous treatment cannot be avoided, monitor the patient's blood pressure and heart rate closely 1. EPINEPHrine has the potential to trigger or worsen angina pectoris and to cause ventricular arrhythmias. Should combined use be necessary, watch patients closely for the onset of cardiac arrhythmias 2.
Why it happens (mechanism)
Unknown
How to manage this interaction
This combination is generally avoided when possible, but sometimes epinephrine is needed (for example, in an emergency or certain procedures). Keep taking your atenolol as prescribed and do not change anything on your own.
- If both must be used, your care team will monitor your blood pressure and heart rate closely.
- They will watch for chest pain (angina) and irregular or slow heartbeats.
- The plan may need to be individualized by your care team based on your response.
Tell your pharmacist or doctor you take atenolol before any procedure, and mention any dizziness, chest pain, palpitations, or a very slow pulse right away.
Management is individual — confirm any change with your pharmacist or prescriber.
Literature reports
5 reports — tap to read
a) When EPINEPHrine is given by inhalation, giving propranolol at the same time may block the EPINEPHrine-induced bronchodilatation (which works through beta-2 receptors) and raise the patient's blood pressure (because alpha stimulation is left unopposed), particularly when the EPINEPHrine dose is given again. In a patient taking chronic oral propranolol, EPINEPHrine was unable to reverse an anaphylactic reaction to a maintenance allergy injection. Supportive care involved intubation, neuromuscular blockade, an antihistamine, and steroids 3. In contrast, cardioselective beta blockers (atenolol, metoprolol, acebutolol) seem to have minimal effect on the pressor response to EPINEPHrine, and low doses are unlikely to interfere with EPINEPHrine-induced bronchodilatation. How larger doses affect the bronchodilatation caused by EPINEPHrine has not been well studied at this time 4.
b) Acute hypertension followed by a reflex bradycardia may develop when propranolol (or other nonselective beta-blockers) is used together with EPINEPHrine 56. The rise in blood pressure results from blockade of beta-receptors, which leaves alpha-receptors dominant and produces a paradoxical hypertension. The bradycardia is a secondary reflex cardiac response mediated by the vagally-innervated aortic arch and carotid baroreceptors. Propranolol produces this later effect by preventing the cardiovascular system from responding appropriately to this additional stress. Increased peripheral resistance raises the workload of the myocardium, which cannot be stimulated to increase its output, thereby producing reflex bradycardia. This chain of events may lead to cardiac arrest or hypertensive stroke 76.
c) In a healthy 22-year-old male, pretreatment with propranolol followed by an EPINEPHrine infusion was reported to reduce the pulse rate to 30 beats per minute with first- and second-degree AV block 6. In 4 hypertensive patients and 5 normal subjects, EPINEPHrine given by itself (0.4 mg subcutaneously) raised the heart rate and had minimal effects on blood pressure; however, after pretreatment with propranolol (40 mg orally), EPINEPHrine caused a 20 to 40 mmHg increase in blood pressure and a 23 to 26 beats per minute reduction in heart rate 8.
d) An interaction was shown in a hemodynamic study assessing the effect of low-dose EPINEPHrine (intended to mimic situations of everyday life stress) in patients receiving either propranolol or metoprolol. EPINEPHrine was infused at graded rates of 0.5, 1, 2, and 4 mcg/min, with each dose maintained for 8 minutes. While the hypertensive patients were kept on propranolol 80 mg/day, low-dose EPINEPHrine infusion produced a marked increase in both systolic and diastolic blood pressure and reductions in heart rate. However, while patients were kept on metoprolol 100 mg daily, EPINEPHrine infusion caused only a slight rise in blood pressure and an increase in heart rate. The effect of EPINEPHrine may be relevant to the choice of which beta-blocker to use for treating hypertension. Metoprolol, because it is selective for beta-1 receptor blockade, appears to be a better choice than propranolol for treating hypertension 5.
e) Nonselective beta blockers such as carvedilol may also produce resistance to EPINEPHrine in cases of anaphylaxis 39. When nonselective beta blockers are used concurrently with EPINEPHrine, the result is a hypertensive response to EPINEPHrine and a reflex bradycardia. This is well-documented with propranolol and is expected to occur with carvedilol as well. Nonselective beta blockers block the beta effects of EPINEPHrine, leaving the alpha effects unopposed 1011. Other nonselective beta blockers such as labetalol are expected to produce the same effect, although labetalol appears to have less impact than propranolol on blocking the vasodepressor and chronotropic effects of EPINEPHrine 12.
Common questions
Can I take Epinephrine and Atenolol together?
Combining epinephrine with the beta-blocker atenolol can cause dangerously high blood pressure and a slow or irregular heartbeat, so it is usually avoided; if both are needed, your care team will monitor your blood pressure and heart rate closely. Always confirm with your pharmacist or prescriber before making any change.
How serious is the Epinephrine and Atenolol interaction?
It is rated major. Potentially serious — often needs a change or close monitoring.
How quickly could this interaction happen?
The documented onset is "unspecified". The timing of this interaction is not well characterized.
How is the Epinephrine and Atenolol interaction managed?
This combination is generally avoided when possible, but sometimes epinephrine is needed (for example, in an emergency or certain procedures). Keep taking your atenolol as prescribed and do not change anything on your own. If both must be used, your care team will monitor your blood pressure and heart rate closely. They will watch for chest pain (angina) and irregular or slow heartbeats. The plan… Management is individual — always follow your own care team's guidance.
How strong is the evidence for this interaction?
The evidence is graded "probable". Good supporting evidence, though not definitively proven.
Questions for your pharmacist
- Does my dose of Epinephrine or Atenolol need adjusting while I take them together?
- What symptoms should prompt me to call you or my prescriber right away?
- Does the timing of my doses matter for this combination?
- Is there a safer alternative to one of these medications for me?
References (12)
- Product Information: FLAVALTA injection solution, lidocaine hydrochloride and epinephrine injection solution. SEPTODONT Inc. Lancaster, PA, 2026. DailyMed
- Product Information: NEFFY(R) nasal spray, epinephrine nasal spray. ARS Pharmaceuticals Operations, Inc. (per FDA), San Diego, CA, 2024. DailyMed
- Newman BR & Schultz LK: Epinephrine-resistant anaphylaxis in a patient taking propranolol hydrochloride. Ann Allergy 1981; 47:35-37.
- Pollack CV Jr: Utility of glucagon in the emergency department. J Emerg Med 1993; 11:195-205. PubMed
- Houben H, Thien T, & van't Laar A: Effect of low dose epinephrine infusion on hemodynamics after selective and nonselective beta-blockade in hypertension. Clin Pharmacol Ther 1982; 31:685-690.
- Kram J, Bourne HR, Melmon KL, et al: Propranolol (letter). Ann Intern Med 1974; 80:282.
- Foster CA & Aston SJ: Propranolol-epinephrine interaction: a potential disaster. Plast Reconstr Surg 1983; 72:74-78. PubMed
- Varma DR, Shama KK, & Arora RC: Response to adrenalin and propranolol in hyperthyroidism. Lancet 1976; 1:260.
- Awai LE & Mekori YA: Insect sting anaphylaxis and beta-adrenergic blockade: a relative contraindication. Ann Allergy 1984; 53:48-49.
- Gandy W: Severe epinephrine-propranolol interaction. Ann Emerg Med 1989; 18:98-99.
- van Herwaarden CL, Binkhorst RA, Fennis JF, et al: Effects of adrenaline during treatment with propranolol and metoprolol (letter). Br Med J 1977; 1:1029. PubMed
- Doshi BS, Kulkarni RD, Dattani KK, et al: Effects of labetalol and propranolol on responses to adrenaline infusion in healthy volunteers. Int J Clin Pharm Res 1984; 4:29-33.
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