Propranolol Dosing for Severe Autism Spectrum Disorder
For individuals with severe autism spectrum disorder (ASD), propranolol should be dosed at 0.5-1 mg/kg/day initially, with a target maintenance dose of 1-3 mg/kg/day divided into 2-3 daily doses, based on symptom response and tolerability. 1
Dosing Algorithm
Initial Dosing
- Starting dose: 0.5-1 mg/kg/day divided into 2-3 doses 1
- For patients with comorbidities or risk factors for hypoglycemia, start at the lower end (0.5 mg/kg/day)
- Use propranolol oral solution (5 mg/5 mL) for precise dosing, especially in children
Dose Titration
- Increase dose gradually at minimum intervals of 24 hours 1
- Monitor for clinical response and side effects
- Titrate to target dose of 1-3 mg/kg/day based on symptom control
- Maximum dose for non-responders: 3 mg/kg/day 1
Target Symptoms and Dosing Considerations
- For hyperactivity: 0.5-1 mg/kg/day has shown efficacy 1
- For self-injurious behavior: 0.5-1 mg/kg/day 1
- For severe challenging behaviors: Higher doses (120-960 mg/day, mean 462 mg) have been used in clinical practice 2
Monitoring Parameters
Before Starting Treatment
- Cardiovascular and respiratory examination (auscultation, peripheral pulses) 1
- Baseline heart rate and blood pressure
- Consider ECG in patients with cardiac risk factors
During Treatment
- Heart rate and blood pressure at follow-up visits
- Monitor for signs of hypoglycemia (especially in at-risk patients)
- Assess for clinical response using standardized measures when possible
- Follow-up every 2-3 months for stable patients 1
Evidence for Efficacy
Propranolol has demonstrated efficacy for several target symptoms in ASD:
- Hyperactivity: Significant reduction in hyperactivity with doses of 0.5-1 mg/kg/day 1
- Self-injurious behavior: Positive trend for improvement 1
- Conversational reciprocity: Improved social communication with single-dose challenges 3
- Challenging behaviors: 85% of patients showed improvement on Clinical Global Impression scale with higher doses in a retrospective analysis 2
- Anxiety: Recent RCT showed benefit for anxiety symptoms at 12 weeks (odds ratio = 2.58) 4
Common Side Effects
- Transient sedation 1
- Decreased heart rate and blood pressure
- Potential for increased aggression and stereotypy in some patients 1
- Hypoglycemia (particularly in at-risk individuals)
Clinical Pearls
- Propranolol can be safely discontinued abruptly rather than requiring gradual tapering 1
- Consider as an add-on to existing medications for challenging behaviors 2
- For severe challenging behaviors, higher doses (>120 mg/day) may be required, but should be administered under close clinical supervision 2
- Recent evidence suggests propranolol may be particularly beneficial for anxiety symptoms in ASD 4
- Low-dose propranolol (0.3 mg/kg/day) has shown efficacy for hypersexual behaviors in adolescents with ASD 5
Contraindications
- Hypoglycemic episodes (recent or ongoing)
- Second or third-degree heart block
- Hypersensitivity to propranolol
- Blood pressure or heart rate outside normal range for age (relative contraindication; consider specialist consultation) 1
Propranolol represents a promising pharmacological option for managing specific symptoms in severe ASD, particularly challenging behaviors, hyperactivity, and anxiety. While not FDA-approved specifically for ASD, the evidence supports its use as a targeted intervention for specific symptoms when prescribed and monitored appropriately.