What is the typical dosing regimen for propranolol (beta-blocker) in adults?

Propranolol Dosing in Adults

For hypertension, start with propranolol immediate-release 80-160 mg daily in 2 divided doses, or propranolol long-acting 80 mg once daily, titrating up to 120-160 mg daily for maintenance, with a maximum of 640 mg daily if needed. 1, 2

Standard Dosing by Indication

Hypertension

• Immediate-release formulation: 80-160 mg daily divided into 2 doses 1
• Long-acting (extended-release) formulation: Start 80 mg once daily, increase to 120-160 mg once daily for maintenance 2
• Maximum dose may reach 640 mg daily in some patients 2
• Full antihypertensive response may take days to several weeks at any given dose 2

Angina Pectoris

• Long-acting formulation: Start 80 mg once daily, gradually increase at 3-7 day intervals until optimal response 2
• Average optimal dose is 160 mg once daily 2
• Maximum studied dose is 320 mg daily; safety and efficacy beyond this are not established 2
• Gradual discontinuation over several weeks is mandatory to prevent rebound angina 2

Migraine Prophylaxis

• Start 80 mg long-acting once daily 2
• Usual effective range: 160-240 mg once daily 2
• If no response after 4-6 weeks at maximum dose, discontinue therapy 2

Hypertensive Emergencies (IV formulation)

• Labetalol (combined alpha/beta blocker) is preferred: 0.3-1.0 mg/kg slow IV injection (maximum 20 mg) every 10 minutes, or 0.4-1.0 mg/kg/h IV infusion up to 3 mg/kg/h 1
• Contraindicated in reactive airways disease, heart block, or bradycardia 1

Critical Pre-Treatment Assessment

Mandatory Screening

• Cardiovascular examination: Auscultation, peripheral pulses, blood pressure, heart rate 3, 4
• Screen for absolute contraindications: Second or third-degree heart block, decompensated heart failure, asthma/reactive airway disease, cardiogenic shock, hypotension, recent hypoglycemic episodes 3, 4
• Baseline vital signs: Document heart rate and blood pressure before initiation 3

No Routine Laboratory Testing Required

• Routine blood work (CBC, renal, liver, thyroid function) is not required before starting propranolol in otherwise healthy adults 1
• ECG and echocardiogram only needed in selected cases with cardiac concerns 1

Formulation Considerations

Immediate-Release vs. Long-Acting

• Do not substitute immediate-release for long-acting on a mg-for-mg basis 2
• Long-acting formulations have different kinetics, produce lower blood levels, and require retitration 2
• Long-acting formulations have prolonged terminal half-life (8-11 hours) and 30-50% lower bioavailability than immediate-release 5
• Once-daily long-acting propranolol maintains therapeutic levels and exercise-induced tachycardia inhibition throughout 24 hours 5

Monitoring During Treatment

Ongoing Assessment

• Monitor for hypotension and bradycardia, especially during dose escalation 3, 4
• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
• Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities 3

Special Populations

• Elderly patients: May require lower doses due to altered pharmacokinetics 1
• Diabetic patients: Propranolol may mask hypoglycemia symptoms (tachycardia, tremor) 3

Critical Safety Warnings

Discontinuation Protocol

• Never abruptly discontinue propranolol, especially after chronic use 1, 3, 2
• Abrupt cessation can precipitate rebound hypertension, tachycardia, or angina 1, 3
• Taper gradually over several weeks when discontinuing 2

Absolute Contraindications

• Second or third-degree heart block 1, 3, 4
• Decompensated heart failure 1, 3
• Asthma or obstructive airway disease 1, 4
• Cardiogenic shock 3
• Sinus node dysfunction without pacemaker 3
• Recent or ongoing hypoglycemic episodes 1, 4

Drug Interactions

• Avoid routine combination with nondihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1

Practical Dosing Algorithm

1. Confirm no contraindications (heart block, asthma, decompensated HF, hypotension) 3
2. Obtain baseline heart rate and blood pressure 3
3. For hypertension: Start immediate-release 80 mg twice daily OR long-acting 80 mg once daily 1, 2
4. Titrate upward every 3-7 days based on response and tolerability 2
5. Target maintenance: 120-160 mg daily for most patients 1, 2
6. Monitor for bradycardia and hypotension during titration 3
7. When discontinuing: Taper gradually over several weeks 2