Propranolol: Indications and Dosing Guidelines
Propranolol is indicated for hypertension, angina pectoris, myocardial infarction, cardiac arrhythmias, migraine prophylaxis, essential tremor, hypertrophic subaortic stenosis, and infantile hemangioma, with dosing regimens specific to each condition. 1, 2
Primary Indications and Adult Dosing
Hypertension
- Initial dose: 40 mg twice daily
- Maintenance dose: 120-240 mg daily in divided doses
- Maximum dose: 640 mg daily
- Long-acting formulation: 80-160 mg once daily 1, 2
Angina Pectoris
- Initial dose: 10-40 mg three times daily
- Maintenance dose: 80-320 mg daily in divided doses
- Optimal dose: 500-800 mg daily for severe cases 1, 3
Supraventricular Tachycardia/Arrhythmia
- Oral dose: 10-40 mg three to four times daily
- IV administration: 1 mg over 1 minute, may repeat up to 3 doses 1
Migraine Prophylaxis
- Initial dose: 20 mg three to four times daily
- Maintenance dose: 160-240 mg daily in divided doses 2
Special Populations
Infantile Hemangioma
- Initial dose: 1 mg/kg/day in three divided doses
- Target dose: 2 mg/kg/day in three divided doses
- Maximum dose: 3 mg/kg/day
- Duration: Usually until 8-12 months of age 1
Special Considerations for Infantile Hemangioma
- For preterm infants or those with comorbidities: Start at 0.5 mg/kg/day 1
- Administer with feeding to reduce hypoglycemia risk 1
- Monitor heart rate and blood pressure in infants <4 weeks, preterm, or with comorbidities 1
Administration Considerations
- Administer with food to enhance bioavailability
- For long-acting formulations, take once daily at same time
- Avoid abrupt discontinuation (taper over 1-2 weeks) to prevent rebound tachycardia or exacerbation of angina 1
Contraindications
- Cardiogenic shock
- Sinus bradycardia (heart rate <50 beats/min)
- Greater than first-degree heart block
- Bronchial asthma or reactive airway disease
- Severe heart failure
- Hypersensitivity to propranolol 1
Monitoring Parameters
- Blood pressure and heart rate
- Signs/symptoms of heart failure
- For infantile hemangioma: Monitor blood glucose in at-risk infants 1
Common Side Effects
- Bradycardia
- Hypotension
- Fatigue
- Sleep disturbances
- Cool extremities
- Bronchospasm (in susceptible individuals) 1
Clinical Pearls
Dosage Adjustment: Start with low doses and titrate gradually to minimize side effects, especially in elderly patients or those with hepatic impairment.
Drug Interactions: Use caution with other medications that affect heart rate or blood pressure, particularly calcium channel blockers, which may have additive effects 1.
Perioperative Management: Continue propranolol during perioperative period to prevent withdrawal symptoms and cardiovascular events 4.
Formulations: For infantile hemangioma, use 5 mg/5 mL oral solution to minimize dosing errors 1.
Efficacy Monitoring: For angina, efficacy is dose-dependent; some patients may require higher doses for optimal effect 3.
Bioavailability: Long-acting propranolol has 30-50% less bioavailability than conventional formulations but maintains therapeutic levels over 24 hours 5.