Propranolol Dosing in Adults
For hypertension in adults, start propranolol immediate-release at 80-160 mg daily divided into 2 doses, or propranolol long-acting at 80 mg once daily, with a usual maintenance dose of 120-160 mg daily and a maximum of 640 mg daily if needed. 1, 2
Dosing by Indication
Hypertension
- Immediate-release formulation: 80-160 mg daily divided into 2 doses 1
- Long-acting formulation: Start at 80 mg once daily, increase to 120-160 mg once daily for maintenance 2
- Maximum dose may reach 640 mg daily in some patients 1, 2
- Full antihypertensive response may take days to several weeks at any given dose 2
Angina Pectoris
- Start at 80 mg long-acting once daily 2
- Increase gradually 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 beyond this is not established 2
Migraine Prophylaxis
- Initial dose: 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 with gradual taper 2
Hypertrophic Subaortic Stenosis
- Usual dose: 80-160 mg long-acting once daily 2
Critical Pre-Treatment Assessment
Before initiating propranolol, screen for absolute contraindications including second or third-degree heart block, decompensated heart failure, asthma/obstructive airway disease, cardiogenic shock, and sinus node dysfunction without pacemaker. 3
- Measure baseline heart rate and blood pressure 3
- Perform cardiovascular examination with auscultation 3
- Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 3
- ECG and echocardiogram are only needed in selected cases with cardiac concerns 3
- Routine blood work (CBC, renal, liver, thyroid function) is not required in otherwise healthy adults 3
Monitoring During Treatment
- Monitor for hypotension and bradycardia, especially during dose escalation 3
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 3
- Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities, and potential worsening of heart failure 3
Important Safety Considerations
Never abruptly discontinue propranolol, especially after chronic use—taper gradually over several weeks to avoid rebound hypertension, tachycardia, or angina. 1, 3
- Propranolol may mask symptoms of hypoglycemia in diabetic patients 3
- Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1, 3
- Elderly patients may require lower doses due to altered pharmacokinetics 3
Formulation Considerations
- Immediate-release propranolol requires twice-daily dosing (80-160 mg total daily dose divided) 1
- Long-acting formulations allow once-daily dosing but are not simple mg-for-mg substitutes for immediate-release 2
- When switching from immediate-release to extended-release, retitration may be necessary to maintain effectiveness, especially at the end of the 24-hour dosing interval 2
Relative Efficacy by Dose
Research demonstrates that relatively low doses (80-160 mg daily) induce most of the antihypertensive effect of propranolol, with minimal additional benefit at higher doses. 4 Complete cardiac beta-blockade may not be necessary for full hypotensive effect. 4