What is the initial dose of propranolol (beta-blocker) for a patient?

Initial Propranolol Dosing

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

Adult Dosing by Indication

Hypertension

• Initial dose: 80 mg extended-release once daily OR 40 mg immediate-release twice daily 1, 2
• Maintenance: Titrate to 120-160 mg daily based on blood pressure response 1, 2
• Maximum: 640 mg daily if needed, though doses above 320 mg rarely provide additional benefit 2
• Full blood pressure response may take several days to weeks 2

Performance Anxiety/Situational Anxiety

• As-needed dosing: 10-40 mg immediate-release taken 30-60 minutes before the anxiety-provoking event 3
• Regular dosing: Start 30-60 mg daily in divided doses if chronic treatment needed 1
• Most effective when somatic symptoms (tremor, palpitations, sweating) predominate rather than cognitive anxiety 3

Angina Pectoris

• Initial dose: 80 mg extended-release once daily 2
• Titration: Increase gradually at 3-7 day intervals until optimal response 2
• Maintenance: Average optimal dose is 160 mg once daily 2
• Maximum: Safety not established above 320 mg daily 2

Migraine Prophylaxis

• Initial dose: 80 mg extended-release once daily 2
• Effective range: 160-240 mg once daily 2
• Discontinue if no response after 4-6 weeks at maximum dose 2

Pediatric Dosing (Infantile Hemangiomas)

Standard Initiation

• Starting dose: 1 mg/kg/day divided into 3 doses (e.g., 0.33 mg/kg three times daily) 4, 5
• Maintenance: Can be divided into 2 or 3 daily doses after initial stabilization 4
• Maximum: 3 mg/kg/day for inadequate responders 4, 5

High-Risk Infants (Preterm, Low Weight, Comorbidities)

• Starting dose: 0.5 mg/kg/day divided into 3 doses 4, 5
• Use this lower dose for preterm infants, low-weight neonates with faltering growth, poor feeding, or history of hypoglycemia 4

PHACES Syndrome (Cervicofacial Segmental Hemangiomas)

• Starting dose: Maximum 0.5 mg/kg/day in 3 divided doses 4
• Requires cardiac assessment (ECG, echocardiogram) before initiation 4
• Ideally obtain cerebral MRA before starting; if arterial stenosis present, consult pediatric neurology before initiating or increasing dose 4

Special Populations

Severe Liver Disease (Albumin <30 g/L)

• Starting dose: 20 mg immediate-release three times daily OR 80 mg extended-release daily 6
• Initiate in hospital setting with heart rate monitoring 6
• These patients have reduced protein binding and prolonged drug clearance, leading to higher plasma concentrations 6

Elderly Patients

• Lower doses may be required due to altered pharmacokinetics 1
• Start at the lower end of the dosing range and titrate cautiously 1

Mandatory Pre-Treatment Assessment

Absolute Contraindications to Screen For

• Second or third-degree heart block 1, 3, 2
• Decompensated heart failure 1, 3, 2
• Asthma or obstructive airway disease 1, 3, 2
• Cardiogenic shock 1
• Sinus node dysfunction without pacemaker 1
• History of hypoglycemic episodes 5

Baseline Assessment Required

• Heart rate and blood pressure measurement 1, 3
• Cardiovascular examination with auscultation 3
• History screening for: bronchospasm, diabetes, concurrent medications affecting cardiac conduction 1, 3
• Routine blood work NOT required in otherwise healthy adults 1
• ECG and echocardiogram only needed if cardiac concerns or segmental head/neck hemangiomas in children 4, 1

Pediatric-Specific Assessment

• Blood glucose monitoring only needed in at-risk infants (preterm, low weight, poor feeding, history of hypoglycemia) 4
• Ensure regular feeding schedule; hold propranolol if feeding reduced due to illness 4

Critical Safety Warnings

Never Abruptly Discontinue

• Taper gradually over several weeks when stopping, especially after chronic use 1, 3, 2
• Abrupt discontinuation can precipitate rebound hypertension, tachycardia, or angina 1, 3

Drug Interactions to Avoid

• Do not routinely combine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1

Monitoring During Treatment

• No routine vital sign monitoring required between appointments if patient stable and asymptomatic 1
• Monitor for hypotension and bradycardia, especially during dose escalation 1, 5
• Temporarily discontinue if: wheezing requiring treatment, significantly reduced oral intake, or vomiting 4

Common Adverse Effects

• Fatigue, bradycardia, hypotension, dizziness, cold extremities 1, 3
• Propranolol may mask hypoglycemia symptoms in diabetic patients 1, 3