What are the uses and dosing guidelines for propranolol (beta-blocker)?

Propranolol: Clinical Uses and Dosing Guidelines

Primary Indications and Dosing

Propranolol is a non-selective beta-blocker with established efficacy across multiple cardiovascular and non-cardiovascular conditions, requiring scheduled (not PRN) administration with specific dosing tailored to the indication. 1

Infantile Hemangiomas

• Dose 2-3 mg/kg/day divided into multiple daily doses (typically twice daily), targeting a maintenance dose of 1.7 mg/kg twice daily (3.4 mg/kg/day total). 2
• Start at 0.6 mg/kg twice daily and gradually increase over 2 weeks to the maintenance dose 2
• Continue therapy for at least 6 months, preferably until 12-15 months of age to minimize rebound growth risk 2
• Lower doses (1-2 mg/kg/day) may be necessary in patients with PHACE syndrome, sleep disturbances, or progressive ulceration 2
• Must be administered with or immediately after feeding; hold doses during vomiting or diminished oral intake to prevent hypoglycemia 2, 1

Hypertension

• Initial dose: 80 mg once daily (extended-release formulation), whether used alone or with a diuretic 3
• Titrate to 120-160 mg once daily for maintenance; maximum 640 mg daily may be required 3
• For immediate-release formulations: 20-80 mg twice daily 2
• Full antihypertensive response may take days to several weeks 3

Angina Pectoris

• Start with 80 mg once daily (extended-release), gradually increase at 3-7 day intervals until optimal response 3
• Average optimal dose: 160 mg once daily; maximum studied dose: 320 mg daily 3
• For immediate-release: 20-80 mg twice daily 2
• Gradual dose reduction over several weeks is mandatory when discontinuing to prevent rebound angina 3, 1

Acute Coronary Syndromes (Unstable Angina/NSTEMI)

• Initiate oral beta-blockers within the first 24 hours in hemodynamically stable patients without contraindications 2
• Avoid intravenous administration in patients with heart failure, hypotension, or high shock risk 2
• Typical oral dosing: 50-200 mg twice daily (metoprolol preferred, but propranolol 20-80 mg twice daily is acceptable) 2

Post-Myocardial Infarction

• Maintenance dose: 180-240 mg/day (divided doses) for secondary prevention, continued for at least 3 years 4
• Reduces total mortality (7.2% vs 9.8% placebo), ASHD mortality (6.2% vs 8.5%), and sudden cardiac death (3.3% vs 4.6%) 4

Atrial Fibrillation (Rate Control)

• Intravenous: 1 mg over 1 minute; repeat as needed every 2 minutes up to 3 doses 2
• Oral: 10-40 mg three to four times daily for immediate-release 2
• Target heart rate control while monitoring for hypotension and bradycardia 2

Migraine Prophylaxis

• Initial dose: 80 mg once daily (extended-release), titrate to 160-240 mg once daily 3
• If no response after 4-6 weeks at maximum dose, discontinue with gradual taper 3

Hypertrophic Subaortic Stenosis

• Usual dose: 80-160 mg once daily (extended-release) 3

Mandatory Pre-Treatment Assessment

Before initiating propranolol, screen for absolute contraindications and obtain baseline vital signs. 1, 5

Absolute Contraindications

• Asthma or reactive airway disease 2, 1, 5
• Second- or third-degree heart block without functioning pacemaker 2, 1, 5
• Decompensated heart failure (rales, S3 gallop, Killip Class II-III) 2, 1, 5
• Sinus bradycardia (<50 bpm) 2
• Hypotension (systolic BP <90 mmHg) 2
• Cardiogenic shock or high shock risk 2
• Marked first-degree AV block (PR interval >0.24 seconds) 2

Baseline Evaluation

• Measure heart rate and blood pressure 1, 5
• Cardiovascular examination with auscultation 5
• ECG assessment for conduction abnormalities 2
• Screen for history of bronchospasm and diabetes 5
• For infantile hemangiomas with high-risk features: MRI/MRA of head and neck, echocardiography 2

Critical Safety Considerations

Administration Requirements

• Propranolol requires scheduled dosing, NOT PRN administration, because therapeutic efficacy depends on consistent beta-blockade 1
• For infantile hemangiomas: administer with or after feeding; hold doses during vomiting or poor oral intake 2, 1
• Extended-release formulations are not mg-for-mg equivalent to immediate-release; retitration may be necessary 3

Monitoring During Treatment

• Monitor heart rate and blood pressure regularly, especially during dose escalation 1, 5
• Watch for hypotension, bradycardia, bronchospasm, and worsening heart failure 5
• In diabetic patients: propranolol masks hypoglycemia symptoms; increased vigilance required 1, 5
• For infantile hemangiomas: monitor for sleep disturbances (may require dose reduction) 2

Discontinuation Protocol

• Never abruptly discontinue propranolol after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 5, 3
• Tapering is especially critical in patients with coronary artery disease 2

Common Pitfalls and Caveats

Dosing Errors

• Do not use propranolol PRN for anxiety or other conditions—it requires continuous beta-blockade for efficacy and safety 1
• Extended-release formulations have 30-50% lower bioavailability than immediate-release; do not substitute without dose adjustment 6
• In infantile hemangiomas, dosing based on hydrochloride salt (3.4 mg/kg/day) differs from base propranolol dosing (2-3 mg/kg/day) 2

High-Risk Populations

• Patients with PHACE syndrome require lower doses (1-2 mg/kg/day), slower titration (three times daily dosing), and co-management with pediatric neurology 2
• Elderly patients and those with renal impairment may require dose reduction 2
• In acute MI, avoid intravenous beta-blockers in patients with tachycardia (reflecting low stroke volume), Killip Class II-III, or systolic BP <90 mmHg 2

Drug Interactions

• Concurrent use with other negative chronotropes (diltiazem, verapamil, digoxin) increases bradycardia and heart block risk 2
• Avoid combining with other QT-prolonging agents 2

Anxiety Disorders: Lack of Evidence

Despite increasing off-label use for anxiety, there is insufficient evidence supporting propranolol's effectiveness for anxiety disorders. 7

• A 2025 systematic review found no beneficial effect compared to placebo or benzodiazepines in social phobia or panic disorder (p ≥0.54 for all comparisons) 7
• If used for performance anxiety, it should be for situational physical symptoms (tremor, palpitations) only, not as chronic therapy 5
• Scheduled dosing with cardiovascular monitoring is still required; PRN use is inappropriate 1