Maximum Dose of Propranolol for Hypertension
The maximum dose of propranolol for hypertension is 640 mg daily, though most patients achieve adequate blood pressure control at 120-160 mg daily, and the dose-response curve typically flattens after 160 mg daily. 1, 2
Standard Dosing Algorithm
Initial Dosing
- Start with 80 mg once daily (extended-release) or 80-160 mg daily in 2 divided doses (immediate-release) 1, 3, 2
- Administer with food to reduce hypoglycemia risk 3
Titration Strategy
- Increase to 120 mg once daily if blood pressure remains uncontrolled after initial dosing 1, 2
- Usual maintenance dose: 120-160 mg once daily for extended-release or divided doses for immediate-release 1, 3
- Time to full hypertensive response is variable, ranging from a few days to several weeks 2
Maximum Dosing
- Absolute maximum: 640 mg daily 1, 2
- However, most antihypertensive effect occurs at 80-160 mg daily, with minimal additional benefit at higher doses 4, 5
- Research demonstrates that the dose-response curve flattens after 160 mg daily, meaning higher doses provide little additional blood pressure reduction 4, 6, 5
Critical Pre-Treatment Assessment
Absolute Contraindications to Screen For
- Second or third-degree heart block 3, 7, 8
- Decompensated heart failure 3, 7, 8
- Asthma or obstructive airway disease 3, 7, 8
- Cardiogenic shock 7, 8
- Sinus node dysfunction without pacemaker 7, 8
- Severe bradycardia or hypotension 8
Baseline Assessment Required
- Heart rate and blood pressure measurement 3, 8
- Cardiovascular examination with auscultation 3
- Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 3, 8
- ECG and echocardiogram only needed if cardiac abnormalities suspected 8
Monitoring During Titration
- Monitor for hypotension and bradycardia, especially during dose escalation 3, 8
- Check heart rate and blood pressure with each significant dose increase 7
- Watch for signs of excessive beta-blockade: dizziness, extreme fatigue, syncope 8
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 3
Common Pitfalls and Safety Considerations
Discontinuation Protocol
- Never abruptly discontinue propranolol after chronic use 1, 3, 7, 8
- Taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 3, 7, 8
Drug Interactions
- Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 3
Special Populations
- Elderly patients require lower starting doses (40 mg twice daily or 80 mg extended-release) and more gradual titration due to increased sensitivity to beta-blockers 8
- Propranolol may mask hypoglycemia symptoms in diabetic patients 3
Temporary Discontinuation Indications
- Hold doses during diminished oral intake or vomiting 3, 8
- Temporarily discontinue if wheezing requiring treatment develops 3
Clinical Context for Dose Selection
Propranolol is not recommended as a first-line agent for hypertension unless the patient has ischemic heart disease or heart failure 1. When used, it is typically combined with a thiazide diuretic, with over 80% of patients achieving control on doses up to 480 mg/day in combination therapy 9. However, research consistently shows that 80-160 mg daily induces most of the antihypertensive effect, with complete cardiac chronotropic beta-blockade not necessary for full hypotensive effect 4.