What is the maximum recommended dose of atenolol (tab atenolol) per day?

Maximum Daily Dose of Atenolol

The maximum recommended dose of atenolol is 200 mg per day for angina pectoris, while for hypertension the maximum effective dose is 100 mg daily, as increasing beyond this is unlikely to produce further benefit. 1

Standard Maximum Dosing by Indication

Hypertension

• Maximum dose: 100 mg once daily 1
• The FDA label explicitly states that "increasing the dosage beyond 100 mg a day is unlikely to produce any further benefit" for hypertension 1
• Initial dosing starts at 50 mg daily, with titration to 100 mg if optimal response is not achieved within 1-2 weeks 1

Angina Pectoris

• Maximum dose: 200 mg once daily 1
• Some patients may require 200 mg once daily for optimal effect, particularly for achieving 24-hour control 1
• The maximum early effect on exercise tolerance occurs with 50-100 mg doses, but higher doses (200 mg) are needed for sustained 24-hour control 1

Acute Myocardial Infarction

• Maximum initial dose: 10 mg IV (given as two 5 mg doses), followed by 100 mg oral daily or 50 mg twice daily 1
• After IV dosing, oral therapy continues at either 100 mg once daily or 50 mg twice daily for 6-9 days 1

Rate Control in Atrial Fibrillation

• Maximum dose: 100 mg daily 2
• The 2023 ACC/AHA/ACCP/HRS guideline lists atenolol dosing as 25-100 mg daily for rate control in AF 2

Critical Dose Adjustments for Renal Impairment

Atenolol is renally eliminated, requiring mandatory dose reduction in renal dysfunction 1:

• Creatinine clearance 15-35 mL/min/1.73m²: Maximum 50 mg daily 1
• Creatinine clearance <15 mL/min/1.73m²: Maximum 25 mg daily 1
• Hemodialysis patients: 25-50 mg after each dialysis session under hospital supervision 1

The elimination half-life increases dramatically from 5.9 hours in normal renal function to 42.1 hours in preuraemic patients 3. No significant accumulation occurs until creatinine clearance falls below 35 mL/min/1.73m² 1.

Evidence Supporting Maximum Dosing

Research demonstrates that 100 mg daily produces optimal blood pressure control in hypertension, with the lowest pressures achieved at this dose showing a 22/15 mmHg reduction compared to placebo 4. Higher doses (200 mg) showed increased side effects, particularly tiredness, without additional blood pressure benefit 4.

For angina, the 200 mg once-daily dose provides superior 24-hour control, though the maximum early effect on exercise tolerance occurs at lower doses of 50-100 mg 1. The higher dose is necessary because at 50-100 mg doses, the effect at 24 hours is attenuated to only 50-75% of that observed with 200 mg once daily 1.

Common Pitfalls to Avoid

• Do not exceed 100 mg daily for hypertension - no additional benefit is gained and side effects increase 1, 4
• Always assess renal function before dosing - failure to adjust for renal impairment leads to drug accumulation and increased adverse effects 1, 3
• Do not abruptly discontinue in angina patients - withdrawal should be gradual with careful observation and limited physical activity 1
• Monitor closely during IV administration - marked falls in blood pressure can occur, particularly in hemodialysis patients 1