Initial Dosing of Propranolol for Various Medical Conditions
The initial dose of propranolol varies by condition: 80 mg once daily for hypertension and angina, 1 mg/kg daily in three divided doses for infantile hemangiomas, and lower doses for anxiety and other conditions, with careful titration based on response and tolerability. 1, 2
Hypertension and Cardiovascular Conditions
- Initial dose is 80 mg once daily when using extended-release capsules 1
- Dosage may be increased to 120-160 mg once daily for maintenance, with some patients requiring up to 640 mg 1
- For angina pectoris, start with 80 mg once daily and gradually increase at 3-7 day intervals until optimal response, with average optimal dosage of 160 mg daily 1
- For hypertrophic subaortic stenosis, the usual dosage is 80-160 mg once daily 1
- For post-myocardial infarction patients, doses of 180-240 mg/day have shown mortality benefits 3
Migraine Prophylaxis
- Initial oral dose is 80 mg once daily using extended-release formulation 1
- Usual effective dose range is 160-240 mg once daily 1
- Dosage may be increased gradually to achieve optimal migraine prophylaxis 1
- If satisfactory response is not obtained within 4-6 weeks after reaching maximal dose, therapy should be discontinued 1
Infantile Hemangiomas
- Starting dose of 1 mg/kg daily in three divided doses 2
- Dose can be increased after 24 hours to 2 mg/kg daily in three divided doses 2
- For preterm infants or those with comorbidities, a lower starting dose of 0.5 mg/kg daily is recommended 2
- For patients with suspected PHACES syndrome, starting dose is 0.5 mg/kg daily 2
- Maximum dose for non-responders is 3 mg/kg daily 2
Anxiety Treatment
- Lower doses are typically used for anxiety compared to cardiovascular indications 4
- Baseline assessment of heart rate and blood pressure is recommended before starting treatment 4
- Monitoring for hypotension and bradycardia is advised, especially at higher doses 4
Special Considerations and Monitoring
- For patients with comorbidities, preterm infants, or those with low weight, more cautious dosing schedules are needed 2
- Propranolol is contraindicated in patients with asthma, obstructive airway disease, decompensated heart failure, second or third-degree heart block, and history of hypoglycemic episodes 4
- When switching from standard propranolol tablets to extended-release capsules, retitration may be necessary as they have different kinetics and produce lower blood levels 1
- Heart rate and blood pressure monitoring is required for certain high-risk patients, particularly during initiation 2
Titration Principles
- Time needed for full hypertensive response to a given dosage may range from a few days to several weeks 1
- For angina, studies show a dose-dependent anti-anginal effect, with progressive reduction in angina attacks as dosage increases 5
- Maximum beta-blockade occurs at plasma propranolol levels of approximately 100 ng/ml, with significant effects beginning at 30 ng/ml 6
- When discontinuing treatment, dosage should be reduced gradually over a period of a few weeks to avoid withdrawal effects 1