What is the typical dosage and usage of propanolol (a beta-blocker) for various medical conditions?

Propranolol Dosage and Usage Guidelines

Propranolol dosing varies by indication, with typical adult dosages ranging from 30-160 mg daily for most conditions, while infantile hemangioma treatment requires weight-based dosing starting at 1 mg/kg/day. 1, 2, 3

Dosing by Indication

Cardiovascular Indications

• Hypertension: Starting dose 40 mg twice daily, with maintenance dose of 120-240 mg daily in divided doses; long-acting formulations can be given once daily at 160 mg 3
• Angina Pectoris: 80-320 mg daily in divided doses (typically 40 mg four times daily or 160 mg once daily with long-acting formulation) 3, 4
• Post-Myocardial Infarction: 180-240 mg daily in divided doses, shown to reduce mortality when continued for at least 3 years 5
• Cardiac Arrhythmias: IV dosing of 0.5-1 mg over 1 minute, repeated up to total dose of 0.1 mg/kg as needed 6

Neurological Indications

• Migraine Prophylaxis: 20-80 mg 3-4 times daily (total daily dose 60-320 mg) 3
• Essential Tremor: Starting with 40 mg twice daily, increasing to 120-320 mg daily in divided doses 1

Dermatological Indications

• Infantile Hemangioma: Starting dose 1 mg/kg/day, maintenance dose 2 mg/kg/day, maximum dose for non-responders 3 mg/kg/day 6, 2
  • For preterm/low weight infants or those with comorbidities: Start with 0.5 mg/kg/day 6
  • For suspected PHACES syndrome: Starting dose 0.5 mg/kg/day 6

Administration Guidelines

• Propranolol can be administered in divided doses (2-3 times daily) or once daily with long-acting formulations 6, 4
• Administer with food to reduce risk of hypoglycemia 1
• For infantile hemangioma, propranolol preparation of 5 mg/5 mL should be used 6
• Treatment can typically be stopped at 1 year of age for infantile hemangioma, with most patients not requiring treatment beyond 17 months 6

Contraindications and Precautions

• Absolute contraindications: Hypersensitivity to propranolol, second or third-degree heart block, hypoglycemic episodes 6
• Relative contraindications: Asthma, obstructive airway disease, decompensated heart failure, pre-excited atrial fibrillation or flutter 6, 1
• Baseline cardiovascular assessment recommended before initiating treatment 1
• May mask symptoms of hypoglycemia in susceptible patients 1
• Avoid abrupt discontinuation to prevent rebound hypertension or tachycardia 1

Monitoring Requirements

• For infantile hemangioma: Routine follow-up every 2-3 months for patients on stable treatment 6
• Blood pressure and heart rate monitoring not routinely needed between appointments if patient is stable 6
• For patients at risk of hypoglycemia (preterm, low weight, faltering growth, neonates), glucose should be checked 6
• For dental procedures: Monitor blood pressure approximately 5 minutes after local anesthesia administration when used with adrenergic vasoconstrictors 7

Special Populations

• For patients with comorbidities likely to lead to hypoglycemia, preterm infants, or those with low weight, more cautious dosing schedules are needed 6, 2
• For patients with suspected PHACES syndrome, brain MRI/MRA should ideally be done before starting full dose 6
• For patients with angina, optimal dosing may require higher doses (500-800 mg daily) for severe cases 8

Pharmacodynamics

• Maximum beta-blockade occurs at plasma propranolol levels of 100 ng/ml 9
• Hypotensive effect begins at plasma levels of approximately 30 ng/ml 9
• Therapeutic benefit in angina occurs at plasma levels of approximately 30 ng/ml 9