Propranolol Dosage for Agitation Management
For managing agitation in adults, propranolol should be initiated at 10-20 mg three times daily and titrated up to 40-80 mg daily, with effectiveness demonstrated at these low doses for reducing aggression and agitation. 1
Dosing Guidelines by Patient Population
Adults with Agitation/Aggression
- Starting dose: 10-20 mg three times daily
- Effective maintenance dose: 40-80 mg daily (divided doses)
- Maximum dose: Consider up to 120 mg daily in severe cases
- Administration: With or after meals to reduce hypoglycemia risk
Special Considerations for Specific Populations
Elderly Patients with Dementia
- Starting dose: Lower at 10 mg daily
- Titration: Increase by 10 mg increments every 3-7 days
- Target dose: 40-80 mg daily has shown effectiveness in reducing aggression in 67% of elderly dementia patients 1
- Monitoring: Close attention to blood pressure and heart rate changes
Critical Care/Acute Agitation
- Dosing: 20-60 mg every 6 hours
- Average effective daily dose: 90 mg
- Benefit: Can reduce need for traditional sedatives by up to 54% 2
Monitoring Parameters
- Cardiovascular: Blood pressure, heart rate (watch for bradycardia <50 bpm)
- Baseline assessment: Complete cardiovascular and respiratory examination before starting
- Ongoing monitoring: Regular assessment of sedation level and agitation scores
Precautions and Contraindications
Absolute contraindications:
- Heart block (second and third degree)
- Hypersensitivity to propranolol
- Hypoglycemic episodes (recent or ongoing)
Relative contraindications:
- Blood pressure or heart rate outside normal range for age
- Frequent wheezing
Clinical Pearls
- Low-dose propranolol (10-80 mg/day) can effectively reduce aggression in 67% of dementia patients within 2 weeks 1
- Higher doses (120-960 mg) have been used for severe challenging behaviors in autism spectrum disorders with 85% showing improvement 3
- When using for agitation, propranolol works through both peripheral beta-blockade and central nervous system effects
- Hold doses during periods of diminished oral intake or vomiting to prevent hypoglycemia
Dose Adjustments
- For renal/hepatic impairment: Start with lower doses (25-50% reduction)
- For elderly patients: Start at the lower end of the dosing range
- For concurrent medications: Be cautious with other sedatives or hypotensive agents
The evidence strongly supports that lower doses of propranolol (40-80 mg daily) are often sufficient for managing agitation while minimizing side effects, particularly in elderly patients 1. This approach offers an effective alternative to traditional antipsychotics or benzodiazepines for agitation management.