Propranolol Dosing Recommendations and Precautions
Propranolol should be dosed between 2-3 mg/kg/day for infantile hemangiomas, 80-160 mg daily for hypertrophic subaortic stenosis, 80-320 mg daily for angina, 160-240 mg daily for migraine prophylaxis, and 80-160 mg daily initially for hypertension, with dosage adjustments based on clinical response and presence of comorbidities. 1, 2, 3
Dosing by Condition
Infantile Hemangiomas
- Starting dose: 1 mg/kg/day 2
- Maintenance dose: 2-3 mg/kg/day 1, 2
- Administration: Divided into 2-3 daily doses 2
- Duration: Minimum 6 months, preferably until at least 12-15 months of age to minimize rebound growth 1
Hypertension
- Initial dose: 80 mg once daily (extended-release) 3
- Maintenance dose: 120-160 mg once daily 3
- Maximum dose: Up to 640 mg may be required in some cases 3
- Note: Full hypertensive response may take several days to weeks 3
Angina Pectoris
- Initial dose: 80 mg once daily (extended-release) 3
- Maintenance dose: Average optimal dose is 160 mg once daily 3
- Maximum dose: 320 mg daily (safety not established beyond this) 3
- Titration: Increase gradually at 3-7 day intervals 3
Migraine Prophylaxis
- Initial dose: 80 mg once daily (extended-release) 3
- Effective dose range: 160-240 mg once daily 3
- Duration: Evaluate efficacy after 4-6 weeks at maximal dose 3
Hypertrophic Subaortic Stenosis
- Usual dose: 80-160 mg once daily (extended-release) 3
Administration Considerations
General Administration
- For infantile hemangiomas:
Formulation Considerations
- Extended-release capsules are not a simple mg-for-mg substitute for immediate-release tablets 3
- Extended-release capsules produce lower blood levels and have different kinetics 3
- Retitration may be necessary when switching formulations 3
Precautions and Contraindications
Contraindications
- Hypersensitivity to propranolol 2
- Asthma or obstructive airway disease 2
- Second or third-degree heart block 2
- Severe bradycardia 3
- Cardiogenic shock 3
- Uncompensated heart failure 3
Special Populations Requiring Dose Adjustment
- PHACE syndrome: Start at 0.5 mg/kg/day 2
- Sleep disturbance: Consider lower dose 1
- Premature or low-weight infants: More cautious dosing 2
- Impaired hepatic or renal function: Use with caution 3
Monitoring and Side Effects
Common Side Effects
- Cardiovascular: Hypotension, bradycardia 2
- Neurological: Sleep disturbances 1, 2
- Metabolic: Hypoglycemia (especially in infants) 1, 2
Monitoring Parameters
- Heart rate and blood pressure
- For infantile hemangiomas: Consider MRI/MRA of head and neck and echocardiography before or shortly after initiation 1
- In patients with hypertension: Monitor serum potassium, transaminases, and alkaline phosphatase 3
Drug Interactions
Important Interactions
- Calcium channel blockers: Risk of bradycardia, hypotension, heart block, and heart failure 3
- Antiarrhythmics (propafenone, quinidine, amiodarone): Enhanced beta-blockade effects 3
- Digitalis glycosides: Increased risk of bradycardia 3
- Drugs affecting CYP2D6, 1A2, or 2C19: May alter propranolol efficacy or toxicity 3
- Alcohol: May increase propranolol plasma levels 3
Discontinuation
- For angina: Reduce dosage gradually over several weeks to avoid withdrawal symptoms 3
- For migraine: May need to withdraw gradually over several weeks 3
- For infantile hemangiomas: Can be stopped abruptly at 1 year of age 2
Practical Considerations
- When treating angina or hypertension, relatively low doses (80-160 mg daily) may provide most of the therapeutic effect 4
- Long-acting propranolol 160 mg once daily is as effective as standard propranolol 40 mg four times daily for angina 5
- Once-daily dosing with extended-release formulations may improve patient compliance 6