What is the starting dose of Propranolol (beta-blocker)?

Starting Dose of Propranolol

For adults with cardiovascular indications (hypertension, angina, anxiety), start with propranolol immediate-release 80 mg daily in 2 divided doses (40 mg twice daily), or propranolol extended-release 80 mg once daily. 1, 2

Standard Adult Dosing by Indication

Hypertension

• Initial dose: 80 mg once daily of extended-release formulation, whether used alone or with a diuretic 2
• Immediate-release alternative: 80-160 mg daily divided into 2 doses 1
• Titrate gradually to maintenance dose of 120-160 mg once daily based on blood pressure response 2
• Maximum dose may reach 640 mg daily if needed, though this is rarely required 2

Angina Pectoris

• Start with 80 mg extended-release once daily, then increase gradually at 3-7 day intervals until optimal response 2
• Average optimal dose is 160 mg once daily 2
• For immediate-release formulation, consider starting at lower doses (40 mg 2-3 times daily) and titrating upward based on symptom control and heart rate response 3, 4

Anxiety and Physical Symptoms

• Start with 30-60 mg daily in divided doses or as single dose with long-acting formulations 1
• Lower doses (10-40 mg three or four times daily) may be sufficient for situational anxiety while minimizing side effects 5
• Titrate based on symptom control and tolerability 1

Pediatric Dosing (Infantile Hemangiomas)

• Standard starting dose: 1 mg/kg/day divided into 2-3 doses, administered with food 6, 7
• For suspected PHACES syndrome: Maximum 0.5 mg/kg/day in 3 divided doses until cerebral MRA excludes arterial stenosis 6
• Target maintenance dose: 2-3 mg/kg/day divided into multiple daily doses 7
• Maximum dose: 3 mg/kg/day if inadequate response 6

Special Populations Requiring Dose Reduction

Severe Liver Disease

• Start with 20 mg three times daily of conventional formulation (or 80 mg daily of slow-release) in patients with serum albumin <30 g/L 8
• Initiate therapy in hospital setting with close monitoring 8
• These patients demonstrate significantly elevated steady-state concentrations and prolonged drug elimination 8

Elderly Patients

• Start at lower doses and titrate more gradually due to increased sensitivity to beta-blockers 1, 5
• Consider 40 mg twice daily or 80 mg extended-release as initial dose 1

Mandatory Pre-Treatment Assessment

Before initiating propranolol at any dose, screen for absolute contraindications 1, 7:

• Second or third-degree heart block
• Decompensated heart failure or significant left ventricular dysfunction
• Asthma or obstructive airway disease
• Cardiogenic shock
• Sinus node dysfunction without pacemaker
• Severe bradycardia or hypotension

Baseline cardiovascular assessment should include 1:

• Heart rate and blood pressure measurement
• Cardiovascular examination with auscultation
• ECG and echocardiogram only in patients with suspected cardiac abnormalities or segmental head/neck hemangiomas 6, 1

Critical Dosing Principles

Administration Requirements

• Administer with food to reduce hypoglycemia risk, particularly important in pediatric patients 7
• Hold doses during diminished oral intake or vomiting 6, 7
• Propranolol requires regular scheduled administration, not PRN dosing, because therapeutic efficacy depends on consistent beta-blockade 7

Titration Strategy

• Allow adequate time for full therapeutic response—may range from several days to several weeks at each dose level 2
• Increase doses gradually, typically at 3-7 day intervals for angina, or 2-3 week intervals for hypertension 2
• Never abruptly discontinue propranolol after chronic use; taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 5, 2

Monitoring During Dose Escalation

• Monitor for hypotension and bradycardia, especially during dose escalation 1
• Watch for signs of excessive beta-blockade: dizziness, extreme fatigue, syncope 5
• In diabetic patients, propranolol masks hypoglycemia symptoms—counsel patients accordingly 1, 7

Common Pitfalls to Avoid

• Do not use extended-release formulations as simple mg-for-mg substitutes for immediate-release tablets—extended-release has different kinetics and produces lower blood levels, requiring retitration 2
• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block 1
• Do not start with high doses even if target maintenance doses are higher—the greatest risk of precipitating heart failure occurs at treatment initiation, not with subsequent dose increases 3
• Temporarily discontinue if patient develops wheezing requiring treatment or has significantly reduced oral intake 6, 1