Propranolol Dosing and Usage for Various Medical Conditions
Propranolol dosing varies by indication, with specific regimens recommended for each condition based on clinical evidence and guidelines. 1, 2
Cardiovascular Indications
Hypertension
- Starting 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
- Dose adjustments should be made at intervals of several days to weeks to achieve optimal blood pressure control 2
Angina Pectoris
- Starting dose: 80 mg once daily with extended-release capsules 2
- Dose increases: Gradual increases at 3-7 day intervals 2
- Average optimal dose: 160 mg once daily 2
- Maximum dose: 320 mg daily (safety not established beyond this dose) 2
- For standard (immediate-release) formulation: 40 mg four times daily (equivalent to 160 mg extended-release once daily) 3
Acute Cardiovascular Emergencies
- For stable narrow-complex tachycardias or atrial fibrillation/flutter rate control: 0.5-1 mg IV over 1 minute, repeated to a total dose of 0.1 mg/kg as required 1
- Caution: Avoid in patients with asthma, obstructive airway disease, decompensated heart failure, and pre-excited atrial fibrillation/flutter 1
Post-Myocardial Infarction
- Maintenance dose: 180-240 mg/day (based on serum drug levels) 4
- Duration: At least three years post-MI 4
- Reduces total mortality (7.2% vs 9.8% with placebo) and sudden cardiac death (3.3% vs 4.6%) 4
Neurological Indications
Migraine Prophylaxis
- Initial dose: 80 mg once daily with extended-release capsules 2
- Effective dose range: 160-240 mg once daily 2
- Duration: 4-6 weeks trial to assess efficacy 2
- If ineffective after reaching maximal dose, treatment should be discontinued 2
Pediatric Indications
Infantile Hemangiomas
- Starting dose: 1 mg/kg/day in three divided doses 1
- Maintenance dose: 2 mg/kg/day for uncomplicated patients 1
- Maximum dose for non-responders: 3 mg/kg/day 1
- For patients with PHACES syndrome: Starting dose of 0.5 mg/kg/day before MRI/MRA 1
- Duration: Treatment can typically be stopped at 1 year of age, with most patients not requiring treatment beyond 17 months 1
Special Considerations
Monitoring Requirements
- Cardiovascular examination before starting treatment 1
- Post-first dose monitoring not routinely needed in uncomplicated cases 1
- For high-risk patients (preterm, low weight, etc.), monitor heart rate and blood pressure every 30 minutes for 2-4 hours after first dose 1
- Blood glucose monitoring only needed in patients at risk of hypoglycemia 1
Contraindications
- Hypoglycemic episodes (recent or ongoing) 1
- Second or third-degree heart block 1, 5
- Hypersensitivity to propranolol 1
- Asthma or obstructive airway disease 1, 5
- Decompensated heart failure 1, 5
Administration Pearls
- Administer with or after feeding in infants to reduce hypoglycemia risk 1
- Hold doses during times of diminished oral intake or vomiting 1
- For extended-release formulations, do not substitute on a simple mg-for-mg basis with immediate-release tablets 2
- Abrupt discontinuation should be avoided to prevent rebound hypertension or tachycardia 5
Dose Adjustments
- For hypertrophic subaortic stenosis: 80-160 mg once daily with extended-release capsules 2
- For patients with comorbidities or preterm/low weight infants: More cautious dosing schedule with lower starting doses (typically 0.5 mg/kg/day) 1
- For elderly patients or those with hepatic impairment: Lower doses may be required due to decreased clearance 5