Propranolol Dosing in Adults
For hypertension, start propranolol immediate-release at 80-160 mg daily divided into 2 doses, or long-acting formulation at 80 mg once daily, titrating to a usual maintenance dose of 120-160 mg daily, with a maximum of 640 mg daily if needed. 1, 2, 3
Standard Dosing by Indication
Hypertension
- Immediate-release: 80-160 mg daily divided into 2 doses 2, 3
- Long-acting: Start 80 mg once daily, increase to 120-160 mg once daily for maintenance 1, 2, 3
- Maximum dose: 640 mg daily may be required in some cases 1, 3
- Time to full response is variable, ranging from days to several weeks 3
Angina Pectoris
- Long-acting: Start 80 mg once daily, gradually increase at 3-7 day intervals 3
- Average optimal dose: 160 mg once daily 3
- Maximum studied dose: 320 mg daily (safety beyond this not established) 3
- Must taper gradually over several weeks when discontinuing 3
Palpitations/Symptomatic Tachyarrhythmias
- Immediate-release: 10-40 mg three to four times daily (30-160 mg total daily) 4
- Alternative long-acting: 80 mg once daily, titrating to 120-160 mg daily 4
- Titrate based on symptom control and heart rate response, not weight-based dosing 4
Migraine Prophylaxis
- Long-acting: Start 80 mg once daily 3
- Usual effective range: 160-240 mg once daily 3
- If no response within 4-6 weeks at maximal dose, discontinue therapy 3
Anxiety (Physical Symptoms)
- Immediate-release: 30-60 mg daily in divided doses initially 1
- Maintenance: 40-160 mg daily in divided doses or single dose with long-acting formulations 1
Acute IV Administration
- 1 mg over 1 minute, repeat every 2 minutes as needed up to 3 doses 4
Mandatory Pre-Treatment Assessment
Screen for absolute contraindications before initiating: 1, 2, 4
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or obstructive airway disease
- Cardiogenic shock or hypotension
- Sinus node dysfunction without pacemaker
Baseline evaluation must include: 1, 2, 4
- Heart rate and blood pressure measurement
- Cardiovascular examination with auscultation
- History screening for bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
- ECG and echocardiogram only in selected cases with cardiac concerns 2
Important caveat: Routine blood work (CBC, renal, liver, thyroid function) is NOT required before starting propranolol in otherwise healthy adults 1
Critical Safety Warnings
Never abruptly discontinue propranolol after chronic use—this can precipitate rebound hypertension, tachycardia, or angina. 1, 2, 4, 3 Taper gradually over several weeks when discontinuing.
Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block. 1, 2, 4
Propranolol masks symptoms of hypoglycemia in diabetic patients—counsel patients accordingly. 1, 2, 4
Monitoring During Treatment
- Monitor for hypotension and bradycardia, especially with dose escalation
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
Temporarily hold doses if: 1
- Patient has wheezing requiring treatment
- Significantly reduced oral intake or vomiting occurs
Special Population Considerations
Elderly patients: May require lower doses due to altered pharmacokinetics 1, 4
Patients with comorbidities: Lower doses may be required for those experiencing adverse effects 1
Switching formulations: When switching from immediate-release to long-acting, retitration may be necessary as long-acting produces lower blood levels and has different kinetics—do not consider it a simple mg-for-mg substitute. 3