What is the typical dosage and usage of propranolol for various medical conditions, including hypertension, angina, and arrhythmias?

Propranolol Dosing and Clinical Use

Cardiovascular Indications

Hypertension

For hypertension, initiate propranolol extended-release at 80 mg once daily, titrating to 120-160 mg daily for maintenance, with a maximum of 640 mg daily if needed. 1

• The immediate-release formulation requires 80-160 mg daily divided into 2 doses 2
• Full hypertensive response may take days to several weeks after dose adjustment 1
• When combined with a thiazide diuretic, propranolol up to 480 mg/day achieves blood pressure control in over 80% of patients with mild to moderate hypertension 3

Angina Pectoris

Start with 80 mg extended-release once daily, gradually increasing at 3-7 day intervals until optimal response, with an average effective dose of 160 mg once daily. 1

• The maximum safe and effective dose for angina is 320 mg per day 1
• For severe angina (NYHA class III-IV), the average optimal dosage is 500-800 mg daily, though this requires gradual titration 4
• Patients achieving ≥50% reduction in anginal episodes have nearly four-fold lower mortality compared to those with <50% reduction 5
• Discontinuation must be gradual over several weeks to prevent rebound angina 1

Arrhythmias (Acute Management)

For stable narrow-complex tachycardias unresponsive to adenosine or vagal maneuvers, administer propranolol 0.5-1 mg IV over 1 minute, repeated up to a total dose of 0.1 mg/kg if required. 6

• This indication applies to supraventricular tachycardia, atrial fibrillation/flutter rate control, and certain polymorphic VT associated with acute ischemia or long QT syndrome 6
• Avoid in pre-excited atrial fibrillation/flutter, as propranolol can accelerate ventricular response through the accessory pathway 6

Post-Myocardial Infarction

Propranolol demonstrates a relative risk reduction of 0.73 (95% CI 0.56-0.94) for secondary prevention after MI 7

Non-Cardiovascular Indications

Migraine Prophylaxis

Begin with 80 mg extended-release once daily, with an effective dose range of 160-240 mg once daily. 1

• If no satisfactory response occurs within 4-6 weeks at maximum dose, discontinue therapy 1
• Gradual withdrawal over several weeks is advisable depending on patient age, comorbidities, and dose 1

Infantile Hemangioma

The FDA-approved dose (Hemangeol) is 3.4 mg/kg/day, achieving 60% complete or nearly complete resolution. 6, 7

• Initiate at 1 mg/kg/day, escalating to target dose of 1-3 mg/kg/day (or 3.4 mg/kg/day per FDA approval) 6
• Administer 3 times daily (or twice daily per some protocols) with feedings at intervals not exceeding 8 hours (6 hours in younger infants) to reduce hypoglycemia risk 6
• Consider inpatient initiation for infants ≤8 weeks old, preterm infants <48 weeks postconceptional age, those with poor social support, or cardiac/pulmonary risk factors 6
• Most dramatic improvement occurs within 3-4 months of initiation 6

Performance/Situational Anxiety

Propranolol 10-40 mg taken 30-60 minutes before the anxiety-provoking situation is effective for performance anxiety with prominent somatic symptoms (tremor, palpitations, sweating). 2

• Maximum single dose is 40 mg 2
• This is NOT appropriate for chronic generalized anxiety disorder or social anxiety disorder 2
• Most effective for patients with physical/autonomic symptoms rather than predominantly psychological symptoms 2

Hypertrophic Subaortic Stenosis

The usual dosage is 80-160 mg extended-release once daily 1

Critical Pre-Treatment Assessment

Absolute Contraindications

Screen for the following absolute contraindications before initiating propranolol: 6, 2, 7

• Second or third-degree heart block
• Decompensated heart failure or cardiogenic shock
• Asthma or obstructive airway disease
• Sinus bradycardia or sinus node dysfunction without pacemaker
• Hypotension (systolic BP <100-120 mmHg)
• Known hypersensitivity to propranolol

Baseline Assessment

Perform cardiovascular examination with auscultation, measure heart rate and blood pressure, and screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction. 2

• ECG is recommended for younger infants, those with low heart rate, cardiac examination abnormalities, or family history of congenital heart disease 6
• Routine blood work (CBC, renal, liver, thyroid function) is NOT required in otherwise healthy adults 2
• Echocardiogram is only needed in selected cases with cardiac concerns 2

Monitoring During Therapy

Routine Monitoring

No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic. 2

• Monitor for hypotension and bradycardia, especially during dose escalation 2, 7
• In pediatric patients on propranolol for hemangioma, hold doses during acute illness with vomiting, diarrhea, or diminished oral intake 6

Adverse Effects to Monitor

Common adverse effects include: 2

• Fatigue and dizziness
• Bradycardia and hypotension
• Cold extremities
• Sleep disturbance
• Potential worsening of heart failure
• Masking of hypoglycemia symptoms in diabetic patients 6, 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. 2, 7, 1

• The greatest risk of precipitating heart failure occurs when initiating therapy, even with small starting doses 4
• Once treatment has begun, gradual dose increases represent small pharmacological increments and are safer 4

Drug Interactions

Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block. 2

Special Populations

• Elderly patients may require lower doses due to altered pharmacokinetics 2
• Patients with comorbidities increasing hypoglycemia risk require more cautious dosing 7
• Previous history of heart failure or cardiothoracic ratio >0.5 are relative contraindications, as all such patients developed heart failure within 3 years in one long-term study 5

Pharmacokinetic Considerations

Extended-release propranolol is NOT a simple mg-for-mg substitute for immediate-release formulations. 1

• Extended-release has 30-50% lower bioavailability than immediate-release 8
• Peak levels occur at approximately 6 hours with extended-release versus 1-2 hours with immediate-release 1, 8
• Terminal half-life is 8-11 hours for extended-release versus 3-6 hours for immediate-release 8
• Retitration upward may be necessary when switching formulations, especially to maintain end-of-dose effectiveness 1
• Approximately 90% is protein-bound; propranolol undergoes extensive first-pass hepatic metabolism with only ~25% reaching systemic circulation 1