What is the recommended dosing of propanolol (beta blocker) for treating tremors?

Propranolol Dosing for Tremors

For essential tremor, propranolol should be started at 40-80 mg daily in divided doses and titrated up to 120-240 mg daily, with 120 mg daily being the optimal dose for most patients. 1, 2, 3, 4

Initial Dosing and Titration

• Start with 40-80 mg daily divided into 2-3 doses
• Gradually increase dose over 1-2 weeks based on clinical response
• Target maintenance dose: 120 mg daily (divided into 2-3 doses)
• Maximum dose: 240 mg daily for patients with inadequate response to 120 mg
• Long-acting formulations can be used once daily for improved adherence 5

Efficacy Considerations

• Optimal therapeutic response typically occurs at plasma propranolol concentrations of 20-40 ng/ml, achieved with daily doses of 120-240 mg 2
• Patients with larger amplitude tremors (more severe tremors) tend to show better response to propranolol therapy 3
• Response rates vary, with studies showing:
  • 67-73% of patients experience improvement 1, 6
  • Average tremor reduction of 45-51% at optimal doses 2, 3

Monitoring and Adjustment

• Evaluate clinical response after 2-4 weeks on a stable dose
• If no significant response is seen after a 3-month trial at 120 mg daily, consider:
  • Increasing to 240 mg daily
  • If still ineffective, gradually decrease the dose and discontinue 1

Important Precautions

• Contraindications:

  • AV block greater than first degree or SA node dysfunction (without pacemaker)
  • Decompensated heart failure
  • Severe reactive airway disease
  • Cardiogenic shock 5

• Administration considerations:

  • Administer with food to reduce gastrointestinal side effects
  • Hold doses during periods of diminished oral intake or vomiting to prevent hypoglycemia 7
  • Monitor for hypotension, bradycardia, and bronchospasm, especially during dose titration

Long-term Considerations

• Tolerance may develop in approximately 12.5% of patients with chronic use 6
• Chronic side effects (reported in 17% of patients) may include fatigue, sleep disturbances, and sexual dysfunction 6
• Periodic reassessment of dose and continued need for therapy is recommended

Special Populations

• Elderly patients may require lower initial doses (20-40 mg daily) with more gradual titration
• Patients with renal or hepatic impairment may require dose reduction
• Use caution in patients with diabetes as propranolol may mask symptoms of hypoglycemia

This dosing regimen is supported by multiple studies showing that 120 mg daily is often the optimal dose for essential tremor, with doses up to 240 mg providing additional benefit in some patients but with potentially increased side effects.