Indications and Dosing Guidelines for Propranolol
Propranolol is indicated for multiple conditions including hypertension, angina pectoris, arrhythmias, migraine prophylaxis, essential tremor, infantile hemangioma, and hypertrophic subaortic stenosis, with specific dosing regimens for each condition. 1, 2
Primary Indications and Adult Dosing
Cardiovascular Indications
Hypertension
- Starting dose: 40 mg twice daily
- Maintenance dose: 120-240 mg daily in divided doses
- Extended-release: 80-160 mg once daily 1
Angina Pectoris
- Starting dose: 10-40 mg three times daily
- Maintenance dose: 80-320 mg daily in divided doses
- Optimal dosage for severe angina: 500-800 mg daily 3
Arrhythmias
- Intravenous: 1 mg over 1 minute; repeat as needed every 2 minutes (up to 3 doses)
- Oral: 10-40 mg three to four times daily 2
Rate Control in Atrial Fibrillation
- Intravenous: 1 mg over 1 minute; repeat as needed every 2 minutes (up to 3 doses)
- Oral maintenance: 10-40 mg three to four times daily 2
Non-Cardiovascular Indications
Migraine Prophylaxis
- Dose range: 20-80 mg three to four times daily
- Titrate based on response 1
Essential Tremor
- Starting dose: 40 mg twice daily
- Titrate based on response
Hypertrophic Subaortic Stenosis
- Dose range: 40-80 mg three times daily 1
Pediatric Dosing for Infantile Hemangioma
- Starting dose: 1 mg/kg/day in three divided doses
- Target dose: 2 mg/kg/day in three divided doses
- Maximum dose for non-responders: 3 mg/kg/day
- Duration: Typically until 8-12 months of age (3-12 months of therapy) 2
Formulations
- Immediate-release tablets: 10,20,40,80 mg
- Extended-release capsules (LA): 60,80,120,160 mg
- Oral solution: 5 mg/5 mL (preferred for pediatric use) 2
- Injectable solution: 1 mg/mL
Monitoring Parameters
- Blood pressure and heart rate (especially during dose titration)
- Signs of bronchospasm, bradycardia, or worsening heart failure
- For infantile hemangioma: monitor glucose in at-risk infants 2, 4
Contraindications
- Sinus bradycardia
- Greater than first-degree heart block
- Cardiogenic shock
- Overt cardiac failure
- Severe hypotension
- Bronchial asthma or history of bronchospasm
- Hypersensitivity to propranolol 2
Special Considerations
Cardiovascular Disease
- Use caution in patients with compensated heart failure
- Avoid abrupt discontinuation (may precipitate angina or myocardial infarction)
- Monitor closely in patients with AV block or sinus node dysfunction 4
Infantile Hemangioma Treatment
- Consider inpatient initiation for:
- Infants ≤8 weeks of age
- Preterm infants <48 weeks' postconceptional age
- Patients with cardiac or pulmonary risk factors
- Patients with poor social support 2
- Monitor heart rate and blood pressure before first dose and every 30 minutes for 2-4 hours after first dose in high-risk infants
- Ensure regular feeding (intervals not exceeding 8 hours) to prevent hypoglycemia 2
Common Pitfalls and Caveats
- Abrupt discontinuation: Never stop propranolol suddenly, especially in patients with coronary artery disease (taper over 1-2 weeks)
- Masking of hypoglycemia symptoms: Propranolol can mask tachycardia associated with hypoglycemia
- Drug interactions: Use caution with other drugs having SA/AV nodal-blocking properties
- Perioperative management: Continue propranolol during dental or surgical procedures to prevent withdrawal symptoms 5
- Rebound phenomenon: Stopping propranolol can lead to rebound tachycardia or worsening of underlying condition
- Infantile hemangioma rebound growth: May occur in 6-25% of children after discontinuation, particularly in those with long proliferative stage and large subcutaneous component 2
Propranolol remains one of the most widely prescribed beta-blockers due to its versatility across multiple indications and well-established safety profile when used appropriately.