What is the recommended dosing for propranolol (beta blocker)?

Propranolol Dosing Recommendations

For most indications, propranolol should be dosed between 2-3 mg/kg per day in pediatric patients for infantile hemangiomas, and 120-160 mg daily for adults with hypertension, angina, or migraine. 1, 2

Adult Dosing by Indication

Hypertension

• Initial dose: 80 mg once daily with extended-release capsules 2
• Maintenance dose: 120-160 mg once daily 2
• Maximum dose: Up to 640 mg may be required in some cases 2
• Most of the antihypertensive effect occurs at relatively low doses (80-160 mg daily) 3

Angina Pectoris

• Starting dose: 80 mg once daily with extended-release capsules 2
• Typical effective dose: 160 mg once daily 2
• Maximum dose: 320 mg daily (higher doses have not been established as safe or effective) 2
• Dose should be gradually increased at 3-7 day intervals until optimal response 2

Migraine Prophylaxis

• Initial dose: 80 mg once daily with extended-release capsules 2
• Effective dose range: 160-240 mg once daily 2
• Treatment should be discontinued if no satisfactory response after 4-6 weeks at maximal dose 2

Hypertrophic Subaortic Stenosis

• Usual dosage: 80-160 mg once daily with extended-release capsules 2

Pediatric Dosing for Infantile Hemangiomas

• Recommended dose: 2-3 mg/kg per day 1
• Starting dose: 1 mg/kg per day with gradual titration 1
• FDA-approved formulation (Hemangeol): Starting at 0.6 mg/kg twice daily, increasing over 2 weeks to maintenance dose of 1.7 mg/kg twice daily (3.4 mg/kg/day total) 1
• Duration: Minimum 6 months of therapy is superior to 3 months, with many experts recommending continuing until at least 1 year of age 1

Administration Considerations

• Immediate-release formulations: Typically administered 3-4 times daily due to short half-life (3-6 hours) 4
• Extended-release formulations: Administered once daily 2
• When switching from immediate-release to extended-release, retitration may be necessary as they are not mg-for-mg equivalent 2
• Propranolol should be administered with or after feeding, especially in pediatric patients 1
• Doses should be held during times of diminished oral intake or vomiting to reduce hypoglycemia risk 1

Special Populations and Considerations

• Lower doses may be required for patients with:
  • PHACE syndrome 1
  • Sleep disturbances 1
  • Progressive infantile hemangioma ulceration while on therapy 1
• For high-risk patients requiring treatment:
  • Use lowest effective dose 1
  • Slowly titrate the dose 1
  • Consider administering 3 times daily to minimize blood pressure fluctuations 1
  • Consider co-management with appropriate specialists 1

Safety Monitoring

• Blood pressure and heart rate should be monitored during treatment, particularly at initiation 4
• Contraindications include asthma, obstructive airway disease, decompensated heart failure, and certain cardiac conduction abnormalities 4
• Severe toxicity risk increases with doses ≥2,000 mg in overdose situations 5

Dosing Schedule Considerations

• Twice-daily dosing provides similar beta-blockade efficacy as three-times-daily dosing at the same total daily dose 6
• When discontinuing treatment, dose should be gradually reduced over several weeks to avoid withdrawal effects 2