Propranolol Dosing for Adults
The typical dosing regimen for propranolol in adults varies by indication, with hypertension requiring 80-160 mg once daily (extended-release) or 80-240 mg daily in divided doses (immediate-release), angina requiring 80-320 mg daily, and migraine prophylaxis requiring 160-240 mg daily. 1, 2
Dosing by Indication
Hypertension
- Initial dose: 80 mg once daily (extended-release)
- Maintenance dose: 120-160 mg once daily
- Maximum dose: Up to 640 mg may be required in some cases
- Frequency: Once daily for extended-release; twice daily for immediate-release
- Titration: May increase dose gradually until adequate blood pressure control is achieved 1
Angina Pectoris
- Initial dose: 80 mg once daily (extended-release)
- Maintenance dose: 160 mg once daily (average optimal dosage)
- Maximum dose: 320 mg daily
- Titration: Increase gradually at 3-7 day intervals until optimal response 1
Migraine Prophylaxis
- Initial dose: 80 mg once daily (extended-release)
- Effective dose range: 160-240 mg once daily
- Titration: Increase gradually to achieve optimal prophylaxis
- Duration: If no satisfactory response after 4-6 weeks at maximal dose, discontinue therapy 1
Hypertrophic Subaortic Stenosis
- Usual dosage: 80-160 mg once daily (extended-release) 1
Formulation Considerations
Extended-Release vs. Immediate-Release
- Extended-release (long-acting) propranolol:
- Allows once-daily dosing
- Maintains therapeutic levels throughout 24 hours
- Has 30-50% less bioavailability than immediate-release formulations
- Provides more consistent plasma concentrations 3
- Immediate-release propranolol:
- Typically requires twice-daily dosing
- Higher peak concentrations but shorter duration of action 3
Important Clinical Considerations
- Beta-blockers like propranolol are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 2
- When switching from immediate-release to extended-release formulations, retitration may be necessary as they are not simple mg-for-mg substitutes 1
- If discontinuing treatment, gradually reduce dosage over several weeks to avoid rebound effects 1
- Avoid abrupt cessation of propranolol therapy 4
- Contraindicated in second/third-degree heart block 2
- Use with caution in patients with reactive airway disease 4
Monitoring
- Monitor heart rate and blood pressure response to ensure adequate control
- For hypertension, full response may take several days to weeks 1
- For migraine prophylaxis, evaluate efficacy after 4-6 weeks at optimal dosage 1
The American College of Cardiology notes that propranolol should be avoided in combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 2.