Propranolol Dosing
Start propranolol at 80 mg once daily (extended-release) or 40 mg twice daily (immediate-release) for most indications, titrating upward based on clinical response, with typical maintenance doses of 120-240 mg/day for hypertension and migraine, 160-320 mg/day for angina, and 30-60 mg in divided doses for oral SVT control. 1
Hypertension
- Initial dose: 80 mg once daily (extended-release formulation) 1
- Maintenance dose: 120-160 mg once daily, though some patients may require up to 640 mg daily 1
- Titration: Increase gradually until adequate blood pressure control is achieved; full response may take days to several weeks 1
The FDA label provides clear guidance here, and research supports that even lower doses (80-320 mg) show similar efficacy in mild-to-moderate hypertension 2. The extended-release formulation is not a simple mg-for-mg substitute for immediate-release tablets—retitration may be necessary 1.
Angina Pectoris
- Initial dose: 80 mg once daily (extended-release) 1
- Maintenance dose: 160 mg once daily is the average optimal dose 1
- Maximum: 320 mg/day; doses exceeding this have not been established as safe or effective 1
- Titration: Increase gradually at 3-7 day intervals until optimal response 1
Critical caveat: When discontinuing propranolol in angina patients, taper gradually over several weeks to avoid rebound ischemia 1. Historical data suggests that for severe angina, higher doses (500-800 mg/day immediate-release) may be needed, but this exceeds current FDA-approved dosing for extended-release formulations 3.
Migraine Prophylaxis
- Initial dose: 80 mg once daily (extended-release) 1
- Effective range: 160-240 mg once daily 1
- Titration: Increase gradually to achieve optimal prophylaxis 1
- Trial duration: If no satisfactory response within 4-6 weeks at maximum dose, discontinue and consider alternatives 1
Important finding: Low doses (close to 1 mg/kg/day, approximately 60-80 mg) are effective in 73.5% of patients with severe migraine 4. This suggests starting lower and only escalating if needed. Propranolol receives a strong recommendation in Canadian guidelines for migraine prophylaxis 5, and Cochrane review confirms clear superiority over placebo 6.
Supraventricular Tachycardia
For acute rate control in SVT, the 2015 ACC/AHA/HRS guideline provides oral dosing:
- Oral maintenance: 30-60 mg daily in divided doses or as single dose with long-acting formulations 7
- Maximum: 40-160 mg in divided or single dose with long-acting formulations 7
For IV administration in hypertensive emergencies or acute settings (though not specifically SVT in the guideline excerpt), esmolol is the preferred beta-blocker due to its short half-life and titratable nature 8.
Research note: Continuous IV propranolol infusions (loading dose ~52 mcg/kg, maintenance 16 mcg/kg/hr, range 3.9-74.9 mcg/kg/hr) have been used successfully for refractory SVT, reducing heart rate from 146 to 98 bpm 9. However, this is not standard practice and requires careful monitoring.
Key Precautions and Contraindications
Absolute contraindications 7, 1:
- AV block greater than first-degree (without pacemaker)
- Sinus node dysfunction (without pacemaker)
- Decompensated heart failure
- Cardiogenic shock
- Severe reactive airway disease/asthma
Common pitfalls:
- Never abruptly discontinue in angina or post-MI patients—taper over weeks 1
- Extended-release formulations produce lower peak levels than immediate-release; don't assume bioequivalence 1, 10
- Propranolol inhibits CYP2D6 and is metabolized by CYP3A4—watch for interactions with drugs like thioridazine (55-369% increase), warfarin (increased PT), and triptans (56-67% increase in AUC) 1
- Cimetidine increases propranolol levels by 46% 1
Formulation Considerations
Extended-release propranolol has 30-50% lower bioavailability than immediate-release due to increased first-pass metabolism, but maintains more stable plasma levels over 24 hours 10. The terminal half-life is 8-11 hours (vs. 3-6 hours for immediate-release) 10. This makes once-daily dosing feasible and may improve compliance, particularly important in chronic conditions like hypertension and migraine prophylaxis.