What is the proper dosing of propanolol (beta-blocker) for various indications?

Propranolol Dosing Guidelines for Various Indications

For most clinical indications, propranolol should be dosed between 2-3 mg/kg/day divided into 2-3 daily doses, with specific adjustments based on the condition being treated. 1

Infantile Hemangioma

Standard Dosing Protocol:

• Starting dose: 1 mg/kg/day divided in three doses 1
• Maintenance dose: 2 mg/kg/day for uncomplicated patients 1
• Maximum dose: 3 mg/kg/day for non-responders 1
• Duration: Treatment typically continued until 1 year of age, with most patients not requiring treatment beyond 17 months 1

Special Populations:

1. Patients with comorbidities/preterm/low weight:

   • More cautious dosing schedule
   • Starting dose: 0.5 mg/kg/day 1
   • Individualized maintenance dose determined by specialist

2. Suspected PHACES syndrome:

   • Starting dose: 0.5 mg/kg/day before brain MRI/MRA 1
   • Requires cardiology and neurology consultation before dose escalation

3. Monitoring requirements:

   • Post-first dose monitoring not routinely needed for healthy term infants >4 weeks
   • For high-risk infants: HR and BP monitoring every 30 minutes for 2-4 hours after first dose
   • Glucose monitoring only for patients at risk of hypoglycemia 1

Hypertension

• Initial dose: 40 mg twice daily or 80 mg once daily (extended-release)
• Maintenance dose: 120-240 mg daily in divided doses
• Maximum dose: 640 mg daily 2
• Formulation options:
  • Standard release: Divided into 2-3 daily doses
  • Extended-release: Once daily dosing 3

Angina Pectoris

• Initial dose: 40 mg 2-3 times daily
• Maintenance dose: 80-320 mg daily divided into 2-4 doses
• Optimal dose for moderate-severe angina: 500-800 mg daily 4
• Extended-release option: 160 mg once daily 2

Migraine Prophylaxis

• Dose range: 20-80 mg 3-4 times daily 2
• Typical starting dose: 20 mg three times daily
• Titration: Increase gradually based on response

Hypertrophic Subaortic Stenosis

• Effective dose range: 40-80 mg three times daily 2

Important Clinical Considerations

Contraindications:

• Heart block (second and third degree)
• Hypoglycemic episodes (recent or ongoing)
• Hypersensitivity to propranolol 1

Relative Contraindications:

• Frequent wheezing
• Blood pressure or heart rate outside normal range for age 1

Dose Adjustment Protocol:

1. Start low: Begin with the lowest effective dose for the indication
2. Titrate gradually: Minimum 24-hour interval between dose increases 1
3. Monitor response: Adjust dose based on clinical response and side effects

Withdrawal Considerations:

• For cardiovascular indications: Never stop abruptly - use a prolonged small dose schedule (30 mg daily for 2 weeks) before complete withdrawal to prevent rebound effects 5
• For infantile hemangioma: Safe to stop abruptly at end of treatment 1

Formulation Selection:

• Use 5 mg/5 mL preparation for pediatric patients to minimize dosing errors 1
• Consider extended-release formulations for once-daily dosing in adults with hypertension or angina 3

Monitoring Parameters

• Heart rate and blood pressure at baseline and follow-up visits
• For infantile hemangioma: Clinical photographs to document response
• For cardiovascular indications: ECG in selected patients

Propranolol's wide therapeutic index allows for significant dose adjustments based on clinical response, but careful attention to starting doses and gradual titration is essential to minimize adverse effects, particularly in patients with cardiac conditions.