What is the proper dosage and administration of propanolol (a beta-blocker) for various medical conditions?

Propranolol Dosing and Administration

Dosing by Clinical Indication

For Infantile Hemangiomas (Pediatric)

Clinicians should dose propranolol between 2 and 3 mg/kg per day for infantile hemangiomas, starting at 1 mg/kg/day and titrating up to a maintenance dose of 2-3 mg/kg/day divided into multiple daily doses. 1

• Start with 1 mg/kg/day divided into 2-3 doses administered with food 2
• Titrate to maintenance dose of 2 mg/kg/day for uncomplicated patients 2
• Maximum dose of 3 mg/kg/day may be used for inadequate response 2
• The FDA-approved propranolol hydrochloride oral solution recommends starting at 0.6 mg/kg twice daily, gradually increasing over 2 weeks to 1.7 mg/kg twice daily (3.4 mg/kg per day total) 1
• A large RCT demonstrated that 3 mg/kg per day for 6 months achieved complete or nearly complete resolution in 60% of patients versus 4% with placebo 1

Special pediatric populations requiring lower doses (0.5 mg/kg/day): 2

• Patients with suspected PHACES syndrome 1, 2
• Preterm infants or those with low weight 2
• Patients with comorbidities increasing hypoglycemia risk 2
• Those experiencing adverse effects like sleep disturbances 1

For Hypertension (Adult)

Start with propranolol immediate-release 80 mg daily in 2 divided doses, or propranolol extended-release (Inderal LA) 80 mg once daily. 3, 4

• Usual maintenance dose is 120-160 mg once daily for extended-release formulation 4
• May increase to 640 mg daily if needed, though response time varies from days to several weeks 4
• Research suggests that 80-160 mg daily produces most of the antihypertensive effect, with complete beta-blockade not necessary for full hypotensive benefit 5

For Angina Pectoris (Adult)

Start with 80 mg Inderal LA once daily, gradually increasing at 3-7 day intervals until optimal response is obtained. 4

• Average optimal dosage is 160 mg once daily 4
• Safety of dosages exceeding 320 mg per day has not been established 4
• Historical research indicates that for severe angina, average optimum dosage is 500-800 mg daily, with dose-response studies showing progressive benefit up to 417 mg daily 6

For Anxiety and Physical Symptoms (Adult)

For anxiety and physical symptoms, start with 30-60 mg daily in divided doses or as a single dose with long-acting formulations. 3

• Lower doses of 10-40 mg three or four times daily are sufficient for situational anxiety while minimizing side effects 3
• Patients with physical symptoms such as tremor, palpitations, and tachycardia are most likely to benefit 7

For Migraine Prophylaxis (Adult)

Start with 80 mg Inderal LA once daily, with usual effective dose range of 160-240 mg once daily. 4

• If satisfactory response is not obtained within 4-6 weeks after reaching maximal dose, discontinue therapy 4
• Withdraw gradually over several weeks depending on patient age, comorbidity, and dose 4

For Hypertrophic Subaortic Stenosis (Adult)

The usual dosage is 80-160 mg Inderal LA once daily. 4

Critical Administration Guidelines

Timing and Food Intake

Propranolol must be administered with or after feeding, and doses must be held during times of diminished oral intake or vomiting to reduce hypoglycemia risk. 1, 3, 7

• This is particularly critical in pediatric patients 1
• Stop propranolol if the child becomes unwell with reduced feeding until normal feeding resumes 2

Titration Principles

• Minimum time interval between dose increases should be 24 hours 2
• For PHACES syndrome patients, administer three times daily to minimize abrupt blood pressure changes 1, 2
• Elderly patients should start at lower doses (40 mg twice daily or 80 mg extended-release) and titrate more gradually 3

Mandatory Pre-Treatment Assessment

Absolute Contraindications to Screen For

Before initiating propranolol, screen for second or third-degree heart block, decompensated heart failure, asthma, cardiogenic shock, sinus node dysfunction, and severe bradycardia or hypotension. 3, 7

Baseline Cardiovascular Assessment

• Measure heart rate and blood pressure 3, 7
• Perform cardiovascular examination with auscultation 7
• ECG and echocardiogram are only needed in patients with suspected cardiac abnormalities or segmental head/neck hemangiomas 3, 7
• Routine blood work (CBC, renal, liver, thyroid function) is not required in otherwise healthy adults 7

Special Monitoring for High-Risk Pediatric Patients

• Patients at higher risk require admission for 2-4 hours on initiation and for dose increments >0.5 mg/kg/day 2
• Measure heart rate and blood pressure before first dose and every 30 minutes for 2-4 hours after first dose 2
• Blood glucose monitoring is only needed in patients at risk for hypoglycemia 2

Critical Safety Considerations

Discontinuation Protocol

Never abruptly discontinue propranolol after chronic use; taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina. 3, 7, 4

• For infantile hemangiomas, rebound growth occurs in 10-25% of patients and is more likely if discontinued before 12 months of age, especially before 9 months 1, 2
• Risk factors for rebound include mixed or deep morphology and female sex 1
• Despite rebound risk, guidelines suggest it is safe to stop treatment abruptly in hemangioma patients 2

Monitoring During Treatment

• Monitor for hypotension and bradycardia, especially during dose escalation 3, 7
• Watch for signs of excessive beta-blockade: dizziness, extreme fatigue, syncope 3
• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 7
• Temporarily discontinue if patient has wheezing requiring treatment 7

Drug Interactions

Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block. 7

Metabolic Considerations

• Propranolol may mask symptoms of hypoglycemia in diabetic patients 7
• Patients with severe liver disease (serum albumin <30 g/L) should start with low doses (20 mg three times daily or 80 mg slow-release daily) with regular heart rate monitoring 8

Duration of Therapy for Infantile Hemangiomas

Continue propranolol therapy for at least 6 months, ideally until at least 12 months of age, with lowest risk of rebound when discontinued between 12-15 months of age. 1, 2

• Six months of therapy is superior to 3 months 1
• Treatment duration in studies ranged from 3-13 months 1

Common Pitfalls

• Dosing errors can occur with different propranolol formulations; the 5 mg/5 mL preparation is recommended as least likely to cause errors 2
• Inderal LA should not be considered a simple mg-for-mg substitute for immediate-release Inderal due to different kinetics and lower blood levels; retitration may be necessary 4
• The greatest danger of precipitating heart failure is at treatment initiation, even with small starting doses, not at higher doses once treatment is established 6
• Propranolol may increase risk of cardiogenic shock in acute myocardial infarction 9