What is the recommended titration rate for propranolol (beta blocker)?

Propranolol Titration Guidelines

Propranolol should be started at 1 mg/kg/day and can be increased to a maintenance dose of 2-3 mg/kg/day with a minimum interval of 24 hours between dose increases. 1

General Titration Protocol for Propranolol

Initial Dosing

• Starting dose: 1 mg/kg/day divided into three doses 1
• Use 5 mg/5 mL preparation to minimize dosing errors 1

Titration Schedule

• Minimum time between dose increases: 24 hours 1
• Target maintenance dose: 2 mg/kg/day for uncomplicated patients 1
• Maximum dose for non-responders: 3 mg/kg/day 1

Monitoring During Titration

• Heart rate and blood pressure monitoring every 30 minutes for 2-4 hours after first dose in high-risk patients 1
• Blood glucose checks only needed in patients at risk of hypoglycemia (preterm, low weight, faltering growth, neonates, history of hypoglycemia) 1

Special Population Considerations

Patients with Comorbidities/Preterm/Low Weight

• More cautious starting and incremental dosing schedule 1
• Consider starting at 0.5 mg/kg/day 1
• Individual dosing regimens determined by supervising physician 1

Patients with PHACE Syndrome

• Starting dose: 0.5 mg/kg/day before brain MRI/MRA 1
• Consult with pediatric neurologist for dosing if arterial stenosis or agenesis is present 1

Administration Recommendations

• Administer with or after feeding to reduce hypoglycemia risk 1
• Hold doses during times of diminished oral intake or vomiting 1
• Can be divided into two or three daily doses at clinician's discretion 1

Cardiovascular Monitoring

• Normal heart rate ranges should be considered when monitoring response:
  • Infant (1-12 months): 72-104 beats/min 1
  • Toddler (1-2 years): 86-106 beats/min 1
• Normal blood pressure ranges should guide titration decisions:
  • Infant (1-12 months): 72-104/37-56 mmHg 1
  • Toddler (1-2 years): 86-106/42-63 mmHg 1

Duration of Treatment

• In infantile hemangioma cases, treatment can typically be stopped at 1 year of age 1
• It is safe to stop propranolol abruptly rather than weaning gradually 1

Common Pitfalls and Caveats

• Avoid starting with high doses, especially in patients with cardiac or respiratory conditions
• Be aware that propranolol can mask signs of hypoglycemia
• Monitor for bradycardia during titration, especially in patients with reduced intravascular volume 2
• For patients with severe liver disease (serum albumin <30 g/L), use lower starting doses (20 mg conventional formulation TID or 80 mg slow-release daily) 3
• When switching from immediate-release to extended-release formulations, retitration may be necessary as they are not simple mg-for-mg substitutes 4

By following these guidelines, propranolol can be safely titrated to achieve optimal therapeutic effects while minimizing adverse events.