Propranolol Dosing Parameters for Blood Pressure Management in an 87-Year-Old Patient
For an 87-year-old patient, propranolol should be initiated at a low dose of 0.5 mg/kg daily in divided doses and carefully titrated based on blood pressure response and tolerability, with close monitoring for hypotension and bradycardia. 1, 2
Initial Dosing and Titration
- Start with a low dose of propranolol, typically 10-20 mg twice daily or three times daily, and gradually increase as needed and tolerated 1, 3
- Titrate slowly over several weeks, with dose adjustments no more frequent than every 1-2 weeks to allow for full effect and assessment of side effects 2, 4
- Maximum daily dose should generally not exceed 160 mg in elderly patients, significantly lower than doses used in younger adults 3, 5
Blood Pressure Parameters and Monitoring
- Target blood pressure should be less aggressive in very elderly patients, with a goal of systolic <150 mmHg and diastolic <90 mmHg 1, 2
- Monitor for orthostatic hypotension by checking blood pressure both sitting and standing, especially after dose increases 1, 4
- Heart rate should be maintained above 50-55 beats per minute to avoid symptomatic bradycardia 1, 5
- Blood pressure should be checked within 2-4 weeks after initiation or dose changes 2, 4
Special Considerations for Elderly Patients
- Consider starting at half the usual adult dose (10 mg twice daily) due to age-related changes in pharmacokinetics 2, 4
- Be vigilant for signs of cognitive impairment, falls, or dizziness which may indicate excessive blood pressure lowering 1, 2
- Assess renal function before initiation and periodically during treatment, as decreased renal clearance may lead to drug accumulation 2, 4
- Consider once-daily dosing only after establishing stable response on multiple daily doses, as this may improve adherence 6
Contraindications and Cautions
- Avoid propranolol in patients with decompensated heart failure, severe bradycardia, heart block, asthma, or COPD 1, 5
- Use with extreme caution in patients with diabetes as it may mask hypoglycemic symptoms 2, 4
- Consider alternative agents if patient has peripheral vascular disease, as beta-blockers can worsen symptoms 2, 4
Combination Therapy
- If blood pressure control is inadequate with propranolol alone, consider adding a thiazide diuretic rather than increasing propranolol dose beyond tolerable limits 2, 7
- The combination of propranolol with a calcium channel blocker may be effective but requires careful monitoring for bradycardia and heart block 2, 8
Monitoring Parameters
- Regular monitoring of heart rate, blood pressure (both sitting and standing), and symptoms of hypotension 1, 2
- Assess for signs of heart failure, including edema, shortness of breath, and fatigue 1, 2
- Monitor renal function and electrolytes, particularly if combined with diuretics 2, 4
- Evaluate cognitive function and risk of falls at each visit 1, 2