Propranolol Dosing for Hypertension and Angina
For hypertension, start propranolol extended-release at 80 mg once daily and titrate to 120-160 mg once daily for maintenance, with a maximum of 640 mg daily if needed; for angina, start at 80 mg once daily and increase gradually every 3-7 days to an average optimal dose of 160 mg once daily, with a maximum of 320 mg daily. 1
Hypertension Dosing
Initial and Maintenance Dosing
- Start with 80 mg of propranolol extended-release once daily, whether used alone or combined with a diuretic 1
- Increase to 120 mg once daily or higher until adequate blood pressure control is achieved 1
- Usual maintenance dose is 120-160 mg once daily 1
- In some cases, doses up to 640 mg daily may be required 1
- Time to full hypertensive response varies from days to several weeks at any given dose 1
Alternative Immediate-Release Formulation
- For immediate-release propranolol, the typical range is 80-160 mg daily in divided doses 2
- Can be administered twice daily for hypertension 2
Angina Pectoris Dosing
Titration Protocol
- Begin with 80 mg propranolol extended-release once daily 1
- Increase dosage gradually at 3-7 day intervals until optimal response is obtained 1
- Average optimal dose is 160 mg once daily 1
- Maximum safe and effective dose is 320 mg per day 1
- For more severe angina, average optimal dosage may be 500-800 mg daily based on older research, though this exceeds current FDA-labeled maximums 3
Discontinuation Protocol
- If stopping treatment, reduce dosage gradually over several weeks to avoid rebound angina 1
- Abrupt cessation should be avoided 2
Important Contraindications and Precautions
Absolute Contraindications
- AV block greater than first degree or SA node dysfunction (without pacemaker) 2
- Decompensated systolic heart failure 2
- Reactive airway disease or asthma 2
- Bradycardia 4
- Hypotension 2
- Cardiogenic shock 2
Monitoring Parameters
- Monitor heart rate and blood pressure with each significant dose increase 4
- Watch for bradycardia (heart rate below normal range) 4
- Monitor for hypotension 4
- Assess for fatigue or sleep disturbances 4
- Check for bronchospasm in susceptible individuals 4
Formulation Considerations
Extended-Release vs Immediate-Release
- Extended-release formulations are NOT mg-for-mg substitutes for immediate-release tablets 1
- Extended-release has different kinetics and produces lower blood levels 1
- Retitration may be necessary when switching formulations, especially to maintain effectiveness at the end of the 24-hour dosing interval 1
- Extended-release provides more consistent plasma concentrations throughout 24 hours 5
- Bioavailability of extended-release is 30-50% less than conventional formulation 5
Common Pitfalls to Avoid
- Never abruptly discontinue propranolol—always taper gradually to prevent rebound hypertension or worsening angina 2, 4, 1
- Do not use in patients with uncontrolled hypoglycemia 4
- Avoid in patients with pre-excited atrial fibrillation or flutter 6
- Do not assume low doses are sufficient—many patients require higher doses for optimal control, particularly in angina 3
- When switching from immediate-release to extended-release, do not use simple dose conversion—reassess and retitrate 1