What is the appropriate dosing for Propranolol (beta blocker)?

From the Guidelines

Propranolol dosing should be initiated at 20 to 80 mg twice daily for angina, as recommended in the guidelines. The choice of beta blocker for an individual patient is based primarily on pharmacokinetic and side effect criteria, as well as on physician familiarity 1.

Key Considerations

• The dosage may vary depending on the condition being treated, with different dosages recommended for hypertension, angina, anxiety, migraine prevention, and essential tremor.
• For angina, the usual dose is 20 to 80 mg twice daily, while for hypertension, the usual starting dose is 40 mg twice daily, which can be increased gradually to 120-240 mg per day 1.
• Propranolol should be taken consistently at the same times each day, with or without food, and should not be stopped abruptly as this can worsen underlying conditions.

Potential Side Effects and Complications

• Side effects may include fatigue, dizziness, and cold extremities.
• Patients with asthma, certain heart conditions, or diabetes should use propranolol with caution due to potential complications.

Monitoring and Adjustments

• Monitoring during beta-blocker therapy should include frequent checks of heart rate and blood pressure, as well as continuous ECG monitoring, and auscultation for rales and bronchospasm 1.
• The target resting heart rate is 50 to 60 beats per minute unless a limiting side effect is reached.
• Selection of the oral agent should include the clinician’s familiarity with the agent, and maintenance doses should be adjusted based on individual patient response.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION General: Propranolol hydrochloride extended-release capsules provide propranolol hydrochloride in a sustained-release capsule for administration once daily. If patients are switched from propranolol hydrochloride tablets to propranolol hydrochloride extended-release capsules, care should be taken to assure that the desired therapeutic effect is maintained Propranolol hydrochloride extended-release capsules should not be considered a simple mg-for-mg substitute for propranolol hydrochloride tablets. Hypertension: The usual initial dosage is 80 mg propranolol hydrochloride extended-release capsules once daily, whether used alone or added to a diuretic. The dosage may be increased to 120 mg once daily or higher until adequate blood pressure control is achieved. The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of 640 mg may be required Angina Pectoris: Starting with 80 mg propranolol hydrochloride extended-release capsules once daily, dosage should be gradually increased at three- to seven-day intervals until optimal response is obtained Although individual patients may respond at any dosage level, the average optimal dosage appears to be 160 mg once daily. Migraine: The initial oral dose is 80 mg propranolol hydrochloride extended-release capsules once daily. The usual effective dose range is 160 to 240 mg once daily. Hypertrophic Subaortic Stenosis: The usual dosage is 80 to 160 mg propranolol hydrochloride extended-release capsules once daily.

The dosing of propranolol varies by condition:

• Hypertension: 80-640 mg once daily, with a usual maintenance dosage of 120-160 mg once daily 2
• Angina Pectoris: 80-320 mg once daily, with an average optimal dosage of 160 mg once daily 2
• Migraine: 80-240 mg once daily, with a usual effective dose range of 160-240 mg once daily 2
• Hypertrophic Subaortic Stenosis: 80-160 mg once daily 2

From the Research

Propranolol Dosing Information

• The optimal dose of propranolol for migraine prophylaxis is still unknown, but studies have shown that low doses, close to or up to 1 mg/kg body weight daily, can be effective in controlling serious migraine bouts in many patients 3.
• For hypertension, propranolol can be administered as a single daily dose, with daily doses ranging from 80-320 mg 4.
• Propranolol is a noncardioselective β-blocker with various indications, including hypertension, pheochromocytoma, myocardial infarction, and migraine prophylaxis 5.
• In adult burn patients, propranolol dosages ranged from 0.1 to 3.8 mg/kg/day, with an average maximum dosage of 0.61 mg/kg/day, and modest dosing resulted in frequent episodes of hypotension or bradycardia 6.
• Beta-adrenergic receptor blockers, including propranolol, can be used in combination with other anti-hypertension drugs to achieve maximal blood pressure control, and may be useful in patients with hyperkinetic circulation, migraine headache, and essential tremor 7.

Dosing Considerations

• Low doses of propranolol may be effective in controlling migraine attacks, and fewer than a third of patients may need higher doses 3.
• Propranolol doses should be adjusted based on patient response and tolerance, as higher doses may increase the risk of side effects such as hypotension and bradycardia 6.
• The selection of a β-blocker, including propranolol, should be based on various pharmacologic properties, such as degree of intrinsic sympathomimetic activity, membrane stabilizing activity, and β1 selectivity 7.