I don't think it's a good idea to take a high dose of Propranolol with SN.

[Talvikki]

I don't think it's a good idea to take a high dose of Propranolol with SN.

A high dose of Propranolol (400mg) with SN is not a good idea for the following reason:

1. A very high dose of a beta-blocker can slow the heart rate and sometimes induce atrial fibrillation, but atrial fibrillation does not occur in everyone.

2. On clinical pharmaceutical grounds an overdose of beta-blocker may in some people induce cardiac fibrillation while in others it may protect against this.

3. More chance of vomiting

4. Low-dose oral propranolol significantly attenuated tachycardia and improved symptoms in POTS. Higher-dose propranolol did not further improve, and may worsen, symptoms.


Explanation

In the past, in the United States, Nembutal was often combined with a beta-blocker (160-360 mg propanolol) so that death would be hastened.

Doctors in the Netherlands disagreed.

1. From the book Guide to a Humane Self-Chosen Death (2008, Dutch version)

22 persons drank a minimum of 6 grams to a maximum of 12 grams of liquid Nembutal, The time to death ranged from 15 minutes to 5.5 hours. In the United States, Nembutal is often accompanied by a beta-blocker (160-360 mg propanolol). There is a idea that a beta-blocker slows down the heartbeat so much that death would be speeded up. Indeed, a very high dose of a beta-blocker can slow the heart rate and sometimes induce atrial fibrillation, but atrial fibrillation does not occur in everyone. Because of this uncertainty, we do not recommend the addition of a beta-blocker. It is also not necessary because 6 grams of a barbiturate by itself is lethal.


2. From the book Guide to a Humane Self-Chosen Death (2006)

22 persons had swallowed 6 - 12 grams of liquid pentobarbital, often preceded by 160 - 360 mg propranolol (a beta-blocker).On average, sleep occurred in less than 6 minutes. Average time to death was 67 minutes (with a range of 15 minutes to 5.5 hours). The authors do not see sound toxicological arguments for the combina-
tion of pentobarbital with a beta-blocker like propranolol, neither do they have empirical data against using it. On clinical pharmaceutical grounds an overdose of beta-blocker may in some people induce cardiac fibrillation while in others it may protect against this. What we do know is that no one has ever woken up after taking 6 grams of a barbiturate provided no life-saving treatment had been started.

3. More chance of vomiting
From the website American Clinicians Academy on Medical Aid in Dying.
https://www.acamaid.org/education-pharmacology/

4. Low dose oral propranolol significantly attenuated tachycardia and improved symptoms in POTS. Higher dose propranolol did not further improve, and may worsen, symptoms.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758650/


Conclusion
A high dose of Propranolol (400mg) is not a good idea.
A dosage range of 10 to 40mg for Anxiety tachycardia (Rapid heart rate) three times a day usually achieves the required response.

they stop tachycardia which is distressing. they also stop the associated increase in cardia output which should speed cerebral hypoxia (peaceful)

counter argument is that in aid in dying, tachyarrhythmias (fast hearbeat) are more quickly lethal than bradyarrhythmias (slow heartbeat).

 

[jodes2]

Thanks for that, very informative. I will now be using a smaller dose of propranolol

 

[Dead Meat]

Really want to thank you for this information, it helps me immensely. Very well written and much Love to you

 

[Snatsbats]

So, should we still take 40mg of propranolol? Or not at all. I mean, it may not speed up the process, but still, high heart rate will make you panic.

 

[TydalWave]

Interesting analysis. Do you know at what dose of propranolol that atrial fibrillation becomes a risk?

I ask because I have been taking low dose propranolol for a while for anxiety and while it has a mild affect on reducing heart rate, I would never claim that this level of dosage (10-40mg) would be an effective dose in the severe level of tachyardia induced with SN.

I would consider lowering the dosage if there is considerable benefit to avoiding this semi-rare occurrence that affects some people; but personally I don't think I would want to take less than 200mg. After all, propranolol is prescribed regularly at doses above 100mg for treatment of non heart related illnesses like migraines and anxiety.

 

[Someone123]

So would 60mg - 80mg be too much?

 

[Zegers]

If 400mg would be too much, what would be more appropriate?

 

[well2hell]

Interesting analysis. Do you know at what dose of propranolol that atrial fibrillation becomes a risk?

I ask because I have been taking low dose propranolol for a while for anxiety and while it has a mild affect on reducing heart rate, I would never claim that this level of dosage (10-40mg) would be an effective dose in the severe level of tachyardia induced with SN.

I would consider lowering the dosage if there is considerable benefit to avoiding this semi-rare occurrence that affects some people; but personally I don't think I would want to take less than 200mg. After all, propranolol is prescribed regularly at doses above 100mg for treatment of non heart related illnesses like migraines and anxiety.

As someone who has severe postural orthostatic tachycardia syndrome (POTS, mentioned by OP) and has been on propanolol for years, I can confirm that a 10 to 40 mg dose would not reduce severe tachycardia sufficiently. A dose of 40 mg reduces my heart rate by about 30 bpm when standing, while reports of SN suicide mention heart rates spiking up to 200 bpm. In general, any heart rate above 70 bpm while lying down feels uncomfortable.

400 mg may sound overkill at first glance, but the maximum daily dose of propanolol ranges from 240 mg to 620 mg (split in multiple doses throughout the day) depending on which condition it is used to treat, so I don't think it is excessive — nor does it put us into overdose territory.

You mention the pentobarbital + propanolol findings from the Guide to a Humane Self-Chosen Death. Since pentobarbital and SN have different modes of action (hypoxic vs hypemic hypoxia), I am not sure that these findings carry over to SN.

If we look at other methods, propanolol was one of the 4 drugs in the mixture used in medical aid in dying, at a dose of 1 gram. Although it was replaced by amitriptyline, which is highly cardiotoxic, in 2019, it did the job well enough — the mean time to death with D-DMP2 was 1.3 hours (max 5.1 h) while DDMA slightly reduced it to 1.1 h (max 4.4 h).

Finally, you say that the American Clinicians Academy in Aid of Dying switched to amitriptyline because it reduces vomiting, but that is untrue. On the questionnaire you linked to, the correct answer to "Propranolol of D-DMP2 was changed to amitriptyline of D-DMA because…" is "In aid in dying, tachyarrhythmias are more quickly lethal than bradyarrhythmias". There is no reason to think that propanolol would increase vomiting because this, and nausea, are listed as uncommon side effects (between 0.1% and 1% of patients). Also, propanolol is simply added to the SN-water solution so the ingested volume of liquid does not increase.

 

[TydalWave]

As someone who has severe postural orthostatic tachycardia syndrome (POTS, mentioned by OP) and has been on propanolol for years, I can confirm that a 10 to 40 mg dose would not reduce severe tachycardia sufficiently. A dose of 40 mg reduces my heart rate by about 30 bpm when standing, while reports of SN suicide mention heart rates spiking up to 200 bpm. In general, any heart rate above 70 bpm while lying down feels uncomfortable.

400 mg may sound overkill at first glance, but the maximum daily dose of propanolol ranges from 240 mg to 620 mg (split in multiple doses throughout the day) depending on which condition it is used to treat, so I don't think it is excessive — nor does it put us into overdose territory.

You mention the pentobarbital + propanolol findings from the Guide to a Humane Self-Chosen Death. Since pentobarbital and SN have different modes of action (hypoxic vs hypemic hypoxia), I am not sure that these findings carry over to SN.

If we look at other methods, propanolol was one of the 4 drugs in the mixture used in medical aid in dying, at a dose of 1 gram. Although it was replaced by amitriptyline, which is highly cardiotoxic, in 2019, it did the job well enough — the mean time to death with D-DMP2 was 1.3 hours (max 5.1 h) while DDMA slightly reduced it to 1.1 h (max 4.4 h).

Finally, you say that the American Clinicians Academy in Aid of Dying switched to amitriptyline because it reduces vomiting, but that is untrue. On the questionnaire you linked to, the correct answer to "Propranolol of D-DMP2 was changed to amitriptyline of D-DMA because…" is "In aid in dying, tachyarrhythmias are more quickly lethal than bradyarrhythmias". There is no reason to think that propanolol would increase vomiting because this, and nausea, are listed as uncommon side effects (between 0.1% and 1% of patients). Also, propanolol is simply added to the SN-water solution so the ingested volume of liquid does not increase.

Just wanted to say thanks for this! Great information and definitely will shape my plan around this.

 

[well2hell]

Just wanted to say thanks for this! Great information and definitely will shape my plan around this.

Looking at the data from the American Clinicians' Academy in Aid of Dying, and considering that the September update to the PPeH calls for a large dose of a benzodiazepine when taking SN (the equivalent of 500 mg diazepam), I would be inclined not to take propanolol as it serves no purpose anymore.

The benzodiazepine will put one to sleep quickly — under 10 minutes — so the tachycardia from SN won't be felt. If it arises before falling asleep (and at this point it should be relatively mild), the benzodiazepine will prevent anxiety.

Further, I will take this back from my previous post: "There is no reason to think that propanolol would increase vomiting because this, and nausea, are listed as uncommon side effects (between 0.1% and 1% of patients)". Propanolol causes hypotension, and given that the dose PPeH calls for is a large one for people who do not take beta-blockers, it will kick in quickly. The resulting dizziness is likely to increase nausea from SN and cause one to vomit.

 

[TydalWave]

Looking at the data from the American Clinicians' Academy in Aid of Dying, and considering that the September update to the PPeH calls for a large dose of a benzodiazepine when taking SN (the equivalent of 500 mg diazepam), I would be inclined not to take propanolol as it serves no purpose anymore.

The benzodiazepine will put one to sleep quickly — under 10 minutes — so the tachycardia from SN won't be felt. If it arises before falling asleep (and at this point it should be relatively mild), the benzodiazepine will prevent anxiety.

Further, I will take this back from my previous post: "There is no reason to think that propanolol would increase vomiting because this, and nausea, are listed as uncommon side effects (between 0.1% and 1% of patients)". Propanolol causes hypotension, and given that the dose PPeH calls for is a large one for people who do not take beta-blockers, it will kick in quickly. The resulting dizziness is likely to increase nausea from SN and cause one to vomit.

I don't have access to a benzo right now though, or I would consider this.

I just don't have easy access to request this from a doctor with my medical history and haven't been able to find a source. I think SN + Meto + Prop may be the best I can muster.

 

[well2hell]

I don't have access to a benzo right now though, or I would consider this.

I just don't have easy access to request this from a doctor with my medical history and haven't been able to find a source. I think SN + Meto + Prop may be the best I can muster.

You can obtain non-scheduled "designer" benzodiazepines (research chemicals) like bromazolam legally.

 

[TydalWave]

You can obtain non-scheduled "designer" benzodiazepines (research chemicals) like bromazolam legally.

Will look into this more... Quicker sedation is definitely a major benefit so I am interested.

I get that there would be less need for propranolol if you are unconcious due to the added benzos, but do you think there would be a significant reason to not use a combination of both (just in case)?

I know it would probably increase the risk of vomiting which is a big factor to take in, but perhaps a smaller dose with the added benzo could be a perfect combo. Lowering tachyardia as you go out of conciousness, and possibly providing a more calm sleep. I mean even if you pass out I assume reducing tachyardia would be a plus, right?

 

[well2hell]

Will look into this more... Quicker sedation is definitely a major benefit so I am interested.

I get that there would be less need for propranolol if you are unconcious due to the added benzos, but do you think there would be a significant reason to not use a combination of both (just in case)?

I know it would probably increase the risk of vomiting which is a big factor to take in, but perhaps a smaller dose with the added benzo could be a perfect combo. Lowering tachyardia as you go out of conciousness, and possibly providing a more calm sleep. I mean even if you pass out I assume reducing tachyardia would be a plus, right?

Reports of aborted SN attempts indicate that the tachycardia gradually increases, as the oxygen blood level falls. With a benzo, it would take less time to fall asleep than the time it takes for the tachycardia to become uncomfortable and the propanolol won't kick in before then.

The American Clinicians' Academy of Medical Aid in Dying, based off the data they collected, indicate that tachycardia is more lethal than bradycardia, so it seems it is counterproductive to reduce tachycardia.

All in all, according to the current evidence, there is no reason to take propanolol with SN as long as a benzo is used, whether to avoid tachycardia or to potentiate SN.

 

[oono]

Looking at the data from the American Clinicians' Academy in Aid of Dying, and considering that the September update to the PPeH calls for a large dose of a benzodiazepine when taking SN (the equivalent of 500 mg diazepam), I would be inclined not to take propanolol as it serves no purpose anymore.

The benzodiazepine will put one to sleep quickly — under 10 minutes — so the tachycardia from SN won't be felt. If it arises before falling asleep (and at this point it should be relatively mild), the benzodiazepine will prevent anxiety.

Further, I will take this back from my previous post: "There is no reason to think that propanolol would increase vomiting because this, and nausea, are listed as uncommon side effects (between 0.1% and 1% of patients)". Propanolol causes hypotension, and given that the dose PPeH calls for is a large one for people who do not take beta-blockers, it will kick in quickly. The resulting dizziness is likely to increase nausea from SN and cause one to vomit.

Thank you for this information. So in the last update of the PPeH they say to take benzodiazepine and that propanolol is no longer needed, do they say when to take the benzodiazepines please? 30 min before taking SN?

 

[well2hell]

Thank you for this information. So in the last update of the PPeH they say to take benzodiazepine and that propanolol is no longer needed, do they say when to take the benzodiazepines please? 30 min before taking SN?

At the same time as SN. The PPeH calls for a large dose of benzodiazepine (e.g. diazepam 500 mg or oxazepam 600 mg) so it cannot be taken before SN because it induces sleep too quickly.

 

[oono]

At the same time as SN. The PPeH calls for a large dose of benzodiazepine (e.g. diazepam 500 mg or oxazepam 600 mg) so it cannot be taken before SN because it induces sleep too quickly.

Ok of course I understand better. It's good news, if it puts us to sleep faster. After that it's a level of vomiting, does a high dose of benzo increase the chances of vomiting?

 

[Octogenarian]

You can obtain non-scheduled "designer" benzodiazepines (research chemicals) like bromazolam legally.

I'll definitely try to get bromazolam. What dose should one take along with SN and Metoclopramide?

 

[well2hell]

Ok of course I understand better. It's good news, if it puts us to sleep faster. After that it's a level of vomiting, does a high dose of benzo increase the chances of vomiting?

I do not know. Vomiting seems to be very rarely reported as a symptom of benzodiazepine overdose, though.

I'll definitely try to get bromazolam. What dose should one take along with SN and Metoclopramide?

The equivalent of 500 mg diazepam, but this is hard to say as no equivalent dosages have been established.

A common dose of bromazolam is said to be 1 to 2 mg (per the Psychonaut Wiki). Bromazolam is structurally related to alprazolam (Xanax) for which the common dose is 0.5 mg and is equivalent to 8 to 10 mg diazepam. Therefore, assuming 1 mg bromazolam is equivalent to 0.5 mg alprazolam, a guesstimate is that 50 to 62.5 mg bromazolam is equivalent to 500 mg diazepam.

Since the American Clinicians' Academy for Medical Aid in Dying calls for 1 g diazepam in their 5 drug lethal mixture (DDMAPh), I suppose the dose can be brought up to 100 or 125 mg bromazolam (Dr Nitschke does mention bromazolam in the September update of the online edition of the PPeH, but I do not remember what dosage he recommended — it was not, however, justified by any evidence.)

 

[well2hell]

From the American Clinicians' Academy for Medical Aid in Dying on why propanolol is best avoided. Their data is based on 161 patients.

Note:

- DDMP2 = digoxin + diazepam + morphine + propanolol

- DDMA = digoxin + diazepam + morphine + amitriptyline

- D-DMP2 and D-DMA: as above but with digoxin taken 30 minutes before the other drugs

"The reason for most of the longer deaths with D-DMP2 is that the myocardium tolerates bradycardias caused by the dig[oxin]/propranolol (we use small EKG rhythm monitors with our patients, so we see the pharmacologic effects on the myocardium). We then took out propranolol and added amitriptyline, to formulate D-DMA (amitriptyline induces tachyarrhythmias and impairs cardiac contractility, as well as causing profound hypotension). And the results are again impressive: See D-DMP2 vs. D-DMA on the graph.

Our times to death again dropped significantly by using D-DMA, now with 90% of deaths occurring in <2 hours. D-DMA is both faster and more reliable than D-DMP2, and markedly better than DDMP2.

In summary: D-DMP2 improves DDMP2 by 33%. D-DMA improves D-DMP2 by another 33%. Compare D-DMA with DDMP2: It's 69% better—a very significant difference."

Source with the graph: https://www.acamaid.org/wp-content/uploads/2021/12/12-5-19-DDMA-instead-of-DDMP2.pdf

 

[Sunset Limited]

From the American Clinicians' Academy for Medical Aid in Dying on why propanolol is best avoided. Their data is based on 161 patients.

Note:

- DDMP2 = digoxin + diazepam + morphine + propanolol

- DDMA = digoxin + diazepam + morphine + amitriptyline

- D-DMP2 and D-DMA: as above but with digoxin taken 30 minutes before the other drugs

"The reason for most of the longer deaths with D-DMP2 is that the myocardium tolerates bradycardias caused by the dig[oxin]/propranolol (we use small EKG rhythm monitors with our patients, so we see the pharmacologic effects on the myocardium). We then took out propranolol and added amitriptyline, to formulate D-DMA (amitriptyline induces tachyarrhythmias and impairs cardiac contractility, as well as causing profound hypotension). And the results are again impressive: See D-DMP2 vs. D-DMA on the graph.

Our times to death again dropped significantly by using D-DMA, now with 90% of deaths occurring in <2 hours. D-DMA is both faster and more reliable than D-DMP2, and markedly better than DDMP2.

In summary: D-DMP2 improves DDMP2 by 33%. D-DMA improves D-DMP2 by another 33%. Compare D-DMA with DDMP2: It's 69% better—a very significant difference."

Source with the graph: https://www.acamaid.org/wp-content/uploads/2021/12/12-5-19-DDMA-instead-of-DDMP2.pdf

I don't understand why they don't opt for propofol + rocuronium like they do in Canada. Deeper sedation, faster, more reliable.

 

[well2hell]

I don't understand why they don't opt for propofol + rocuronium like they do in Canada. Deeper sedation, faster, more reliable.

I think that the ACAMAID aims to help patients die at home, in a comfortable environment with their loved ones, rather than in the hospital (which would be the setting required for administrating propofol + rocuronium).

 

[Sunset Limited]

I think that the ACAMAID aims to help patients die at home, in a comfortable environment with their loved ones, rather than in the hospital (which would be the setting required for administrating propofol + rocuronium).

So good idea. It will look like natural death.

 

[in pain]

Looking at the data from the American Clinicians' Academy in Aid of Dying, and considering that the September update to the PPeH calls for a large dose of a benzodiazepine when taking SN (the equivalent of 500 mg diazepam), I would be inclined not to take propanolol as it serves no purpose anymore.

The benzodiazepine will put one to sleep quickly — under 10 minutes — so the tachycardia from SN won't be felt. If it arises before falling asleep (and at this point it should be relatively mild), the benzodiazepine will prevent anxiety.

Further, I will take this back from my previous post: "There is no reason to think that propanolol would increase vomiting because this, and nausea, are listed as uncommon side effects (between 0.1% and 1% of patients)". Propanolol causes hypotension, and given that the dose PPeH calls for is a large one for people who do not take beta-blockers, it will kick in quickly. The resulting dizziness is likely to increase nausea from SN and cause one to vomit.

The latest SN protocol using diazepam suggests to take it after the SN correct? According to wikipedia on Diazepam absorption: "Peak plasma levels occur between 30 and 90 minutes after oral administration". It doesn't make sense to me in this case why Diazepam would be taken after the SN because you will get peak symptoms from the SN within 5-10 minutes. Unless the anti-emetics speed up gastric emptying so fast that the SN and Diazepam are absorbed immediately?

 

[well2hell]

The latest SN protocol using diazepam suggests to take it after the SN correct? According to wikipedia on Diazepam absorption: "Peak plasma levels occur between 30 and 90 minutes after oral administration". It doesn't make sense to me in this case why Diazepam would be taken after the SN because you will get peak symptoms from the SN within 5-10 minutes. Unless the anti-emetics speed up gastric emptying so fast that the SN and Diazepam are absorbed immediately?

There seems to be two things to disentangle.

1) The effect of diazepam on putting one to sleep after having ingested SN + diazepam (the PPeH recommends taking diazepam immediately after SN).

Indeed, diazepam normally acts within 30 to 60 minutes after administration. However, the PPeH calls for a massive dose — 500 mg — so even if only a little bit is absorbed within 10 minutes, say 10%, this will be a supra-therapeutic dose — it should be enough to put one to sleep quickly.

2) The effect of diazepam after passing out.

Diazepam can cause or aggravate respiratory depression, which is why it is not recommended to take it with opioids, antidepressants or other sedatives. Although respiratory depression is not the mechanism of action of SN, it may help quicken death. This is uncertain, though.

In any case, diazepam is not a requirement. Perhaps the most sensible approach would be taking a normal dose one hour before ingesting SN (but not so much as to fall asleep), so that it reduces the anxiety and SI that the symptoms caused by SN will generate.

 

[in pain]

There seems to be two things to disentangle.

1) The effect of diazepam on putting one to sleep after having ingested SN + diazepam (the PPeH recommends taking diazepam immediately after SN).

Indeed, diazepam normally acts within 30 to 60 minutes after administration. However, the PPeH calls for a massive dose — 500 mg — so even if only a little bit is absorbed within 10 minutes, say 10%, this will be a supra-therapeutic dose — it should be enough to put one to sleep quickly.

2) The effect of diazepam after passing out.

Diazepam can cause or aggravate respiratory depression, which is why it is not recommended to take it with opioids, antidepressants or other sedatives. Although respiratory depression is not the mechanism of action of SN, it may help quicken death. This is uncertain, though.

In any case, diazepam is not a requirement. Perhaps the most sensible approach would be taking a normal dose one hour before ingesting SN (but not so much as to fall asleep), so that it reduces the anxiety and SI that the symptoms caused by SN will generate.

Perhaps 20-25g of SN isn't even needed because this was originally designed to knock you out quickly by taking a mega dose. But if we can take diazepam to knock us out, why do we need to take 10 times the lethal dose of SN.

I'm highly considering somewhere between 8-10g of SN which would be 4-5x the lethal dose. Plus a large amount of diazepam like the PPH suggests. This would mean sleep occurs before the nausea and tachycardia get too intense. Probably also reduced chance of vomiting it up.

 

[well2hell]

Perhaps 20-25g of SN isn't even needed because this was originally designed to knock you out quickly by taking a mega dose. But if we can take diazepam to knock us out, why do we need to take 10 times the lethal dose of SN.

I'm highly considering somewhere between 8-10g of SN which would be 4-5x the lethal dose. Plus a large amount of diazepam like the PPH suggests. This would mean sleep occurs before the nausea and tachycardia get too intense. Probably also reduced chance of vomiting it up.

Benzodiazepines are largely non lethal in overdose. They also have a different mechanism of action than SN (respiratory depression vs methemoglobinemia) so it is unclear if they potentiate the effects of SN.

 

[in pain]

Benzodiazepines are largely non lethal in overdose. They also have a different mechanism of action than SN (respiratory depression vs methemoglobinemia) so it is unclear if they potentiate the effects of SN.

I am with you there. I'm not quite worried about potentiating the SN due to lowered dosage of 8-10g. I think that amount of SN is already several times the required amount to CTB. It is just more likely to take longer. The 20-25g that was previously suggested was for the sole purpose of losing consciousness in 10 minutes roughly, so that you aren't suffering with anxiety and tachycardia for an extended period of time. However if we can go to sleep by taking a mega dose of diazepam at the time of taking SN, we have that part of the equation solved.

Maybe I should clarify, I'm trying to propose a more peaceful SN protocol that puts you to sleep before the peak SN symptoms begin. Diazepam being the peaceful agent. Rather than using such a large dose of SN to speed up the process.

Does my line of thinking check out?

 

[well2hell]

I am with you there. I'm not quite worried about potentiating the SN due to lowered dosage of 8-10g. I think that amount of SN is already several times the required amount to CTB. It is just more likely to take longer. The 20-25g that was previously suggested was for the sole purpose of losing consciousness in 10 minutes roughly, so that you aren't suffering with anxiety and tachycardia for an extended period of time. However if we can go to sleep by taking a mega dose of diazepam at the time of taking SN, we have that part of the equation solved.

Maybe I should clarify, I'm trying to propose a more peaceful SN protocol that puts you to sleep before the peak SN symptoms begin. Diazepam being the peaceful agent. Rather than using such a large dose of SN to speed up the process.

Does my line of thinking check out?

I understand your line of thinking. But it is important to note that the dose of SN matters in the end, because you have to reach a blood methemoglobin level of >= 70% for SN to be fatal. This may or may not happen with 8-10 grams. All we know based on anecdotal reports is that it has definitely happened with doses from 15-25 grams, so better stick to the current evidence to avoid a failed attempt, in my view.

 

[👁️👃👁️]

I don't think it's a good idea to take a high dose of Propranolol with SN.

A high dose of Propranolol (400mg) with SN is not a good idea for the following reason:

1. A very high dose of a beta-blocker can slow the heart rate and sometimes induce atrial fibrillation, but atrial fibrillation does not occur in everyone.

2. On clinical pharmaceutical grounds an overdose of beta-blocker may in some people induce cardiac fibrillation while in others it may protect against this.

3. More chance of vomiting

4. Low-dose oral propranolol significantly attenuated tachycardia and improved symptoms in POTS. Higher-dose propranolol did not further improve, and may worsen, symptoms.


Explanation

In the past, in the United States, Nembutal was often combined with a beta-blocker (160-360 mg propanolol) so that death would be hastened.

Doctors in the Netherlands disagreed.

1. From the book Guide to a Humane Self-Chosen Death (2008, Dutch version)

22 persons drank a minimum of 6 grams to a maximum of 12 grams of liquid Nembutal, The time to death ranged from 15 minutes to 5.5 hours. In the United States, Nembutal is often accompanied by a beta-blocker (160-360 mg propanolol). There is a idea that a beta-blocker slows down the heartbeat so much that death would be speeded up. Indeed, a very high dose of a beta-blocker can slow the heart rate and sometimes induce atrial fibrillation, but atrial fibrillation does not occur in everyone. Because of this uncertainty, we do not recommend the addition of a beta-blocker. It is also not necessary because 6 grams of a barbiturate by itself is lethal.


2. From the book Guide to a Humane Self-Chosen Death (2006)

22 persons had swallowed 6 - 12 grams of liquid pentobarbital, often preceded by 160 - 360 mg propranolol (a beta-blocker).On average, sleep occurred in less than 6 minutes. Average time to death was 67 minutes (with a range of 15 minutes to 5.5 hours). The authors do not see sound toxicological arguments for the combina-
tion of pentobarbital with a beta-blocker like propranolol, neither do they have empirical data against using it. On clinical pharmaceutical grounds an overdose of beta-blocker may in some people induce cardiac fibrillation while in others it may protect against this. What we do know is that no one has ever woken up after taking 6 grams of a barbiturate provided no life-saving treatment had been started.

3. More chance of vomiting
From the website American Clinicians Academy on Medical Aid in Dying.
https://www.acamaid.org/education-pharmacology/

4. Low dose oral propranolol significantly attenuated tachycardia and improved symptoms in POTS. Higher dose propranolol did not further improve, and may worsen, symptoms.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758650/


Conclusion
A high dose of Propranolol (400mg) is not a good idea.
A dosage range of 10 to 40mg for Anxiety tachycardia (Rapid heart rate) three times a day usually achieves the required response.

they stop tachycardia which is distressing. they also stop the associated increase in cardia output which should speed cerebral hypoxia (peaceful)

counter argument is that in aid in dying, tachyarrhythmias (fast hearbeat) are more quickly lethal than bradyarrhythmias (slow heartbeat).

How much do you reckon we take?