Propranolol Immediate-Release Dosing for Hypertension
For hypertension, start propranolol immediate-release at 80-160 mg daily divided into 2 doses, titrate to a maintenance dose of 120-160 mg daily, with a maximum of 640 mg daily if needed. 1
Initial Dosing Strategy
- Begin with 80-160 mg daily divided into 2 doses (e.g., 40-80 mg twice daily at 8 AM and 8 PM) 1, 2
- The twice-daily regimen maintains therapeutic efficacy equivalent to four-times-daily dosing while improving compliance 2
- Once-daily dosing (80-320 mg as a single morning dose) is also effective for patients already controlled on divided doses, though some loss of antihypertensive control may occur at the end of the dosing interval 3, 4
Titration and Maintenance
- Titrate up to 120-160 mg daily for maintenance based on blood pressure response 1
- If inadequate response, doses can be increased up to 480 mg/day when combined with a thiazide diuretic, achieving control in over 80% of patients 5
- Maximum dose is 640 mg daily if needed, though most patients respond to lower doses 1
- Allow adequate time between dose adjustments to assess response
Mandatory Pre-Treatment Assessment
Before initiating propranolol, you must screen for absolute contraindications 1:
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or obstructive airway disease
- Cardiogenic shock
- Sinus node dysfunction without pacemaker
Perform baseline assessment including 1:
- Heart rate and blood pressure measurement
- Cardiovascular examination with auscultation
- Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
Monitoring Requirements
- Baseline cardiovascular assessment is mandatory before starting therapy 1
- Monitor for hypotension and bradycardia, especially during dose escalation 1
- No routine vital sign monitoring required between appointments if the patient is stable and asymptomatic 1
- Routine blood work (CBC, renal, liver, thyroid function) is not required in otherwise healthy adults 1
- ECG and echocardiogram only needed in selected cases with cardiac concerns 1
Critical Safety Considerations
- Never abruptly discontinue propranolol, especially after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1
- Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1
- Propranolol may mask symptoms of hypoglycemia in diabetic patients 1
- Elderly patients may require lower doses due to altered pharmacokinetics 1
Common Adverse Effects
Monitor for 1:
- Fatigue
- Bradycardia
- Hypotension
- Dizziness
- Cold extremities
- Potential worsening of heart failure
Combination Therapy
When propranolol alone is insufficient 5, 6:
- Combine with a thiazide diuretic as the preferred approach, effective in over 80% of patients at doses up to 480 mg/day 5
- Propranolol-hydralazine combination is more effective than either component alone, with typical doses of 80-160 mg propranolol combined with 25-100 mg hydralazine twice daily 6
- The combination prevents hydralazine-induced tachycardia while enhancing blood pressure control 6