Indications and Dosages for Propranolol
Propranolol is indicated for hypertension, angina pectoris, migraine prophylaxis, and hypertrophic subaortic stenosis, with dosages tailored to each condition. 1
FDA-Approved Indications
- Hypertension: Initial dose 80 mg once daily (extended-release), may increase to 120-160 mg once daily for maintenance. In some cases, doses up to 640 mg may be required 1
- Angina Pectoris: Start with 80 mg once daily (extended-release), gradually increase at 3-7 day intervals to optimal response (typically 160 mg daily). Maximum recommended dose is 320 mg daily 1
- Migraine Prophylaxis: Initial dose 80 mg once daily (extended-release), with effective dose range of 160-240 mg once daily 1
- Hypertrophic Subaortic Stenosis: Usual dosage is 80-160 mg once daily (extended-release) 1
Additional Clinical Uses
- Infantile Hemangioma: FDA-approved for pediatric use at 3.4 mg/kg/day, with 60% success rate in complete or nearly complete resolution 2
- Post-Myocardial Infarction: Used for secondary prevention of cardiovascular events, showing relative risk reduction of 0.73 (95% CI 0.56-0.94) 2
- Cardiac Arrhythmias: Used for stable narrow-complex tachycardias when other treatments fail 2
Dosing Considerations
- Immediate-Release Formulation: Typically dosed 2-3 times daily due to shorter half-life 3
- Extended-Release Formulation: Once-daily dosing provides sustained beta-blockade throughout 24 hours with 30-50% less bioavailability than immediate-release 3
- Initiation: Start with lower doses and gradually increase to minimize risk of adverse effects 1
- Discontinuation: Taper gradually over several weeks to avoid rebound hypertension or tachycardia 2, 4
Special Populations
Pediatric Patients (Infantile Hemangioma)
- Initial dose 1 mg/kg/day, with escalation to target dose of 1-3 mg/kg/day 2
- Consider inpatient initiation for infants ≤8 weeks, preterm infants, or those with cardiac/pulmonary risk factors 2
- Duration of therapy typically 3-12 months, until 8-12 months of age 2
Patients with Comorbidities
- More cautious dosing required for patients with comorbidities that increase hypoglycemia risk 2
- For segmental infantile hemangiomas (suspected PHACES syndrome), start with 0.5 mg/kg/day 2
Contraindications
- Sinus bradycardia or heart rate outside normal range for age 2, 4
- Heart block greater than first-degree 2
- Cardiogenic shock or heart failure 2
- Hypotension 2
- Reactive airways disease or asthma 2, 4
- Hypoglycemic episodes (recent or ongoing) 2
- Hypersensitivity to propranolol 2
Monitoring and Safety
- Cardiovascular examination recommended before starting treatment 2, 4
- Monitor for hypotension and bradycardia, especially during initiation 4
- Avoid abrupt discontinuation to prevent rebound hypertension or tachycardia 2, 4
- May mask symptoms of hypoglycemia in susceptible patients 4
- For infantile hemangioma treatment, administer propranolol and feed children at intervals not exceeding 8 hours (6 hours in younger infants) to reduce hypoglycemia risk 2
Clinical Pearls
- In angina pectoris, higher doses (500-800 mg/day) may be required for optimal effect in severe cases, but should be approached gradually 5
- For hypertension, propranolol is typically used as a second-step drug in combination with a thiazide diuretic when diuretic therapy alone is insufficient 6
- Can be safely used concurrently with antidepressants without attenuating the therapeutic effects of the antidepressant 7
- Dental considerations: patients should continue propranolol during dental procedures, but limit use of adrenergic vasoconstrictors 8