Propranolol Dosing Recommendations
For adults with cardiovascular indications (hypertension, angina, post-MI), start propranolol immediate-release at 80 mg daily in 2 divided doses or extended-release 80 mg once daily, titrating to a maintenance dose of 120-160 mg daily, with maximum doses up to 640 mg daily if needed. 1
Adult Dosing by Indication
Hypertension
- Start: 80-160 mg daily in 2 divided doses (immediate-release) 1
- Maintenance: 120-160 mg daily 2
- Maximum: 640 mg daily if needed 1
- Alternative: Extended-release 80 mg once daily, titrating upward 1
Angina Pectoris
- Optimal dosing: Average 500-800 mg daily for moderate to severe angina 3
- Evidence shows: Progressive dose-dependent anti-anginal effect up to 417 mg daily, with no plateau reached 3
- Equivalent dosing: Long-acting 160 mg once daily equals standard 40 mg four times daily 4
- Therapeutic plasma level: Maximum benefit occurs at 30±7 ng/ml, corresponding to 64-98% beta-blockade 5
Post-Myocardial Infarction
- Timing: Initiate 5-21 days post-MI 6, 7
- Maintenance dose: 180-240 mg daily based on serum drug levels 6, 7
- Duration: Continue for at least 3 years 7
- Mortality benefit: 26% reduction in all-cause mortality (7.2% vs 9.8% placebo) 7
Anxiety and Performance Anxiety
- Chronic anxiety: 30-60 mg daily in divided doses or single dose with long-acting formulations 2, 1
- Situational/performance anxiety: 10-40 mg three to four times daily, or single dose of 10-20 mg taken 30-60 minutes before event 2, 1
- Maximum single dose: 40 mg for situational use 2
- Best for: Patients with prominent somatic symptoms (tremor, palpitations, sweating) rather than psychological symptoms 2
Pediatric Dosing (Infantile Hemangiomas)
Standard Dosing Algorithm
- Starting dose: 1 mg/kg/day divided into 2-3 doses with food 6, 8
- Target maintenance: 2-3 mg/kg/day divided into multiple daily doses 6, 1, 8
- Maximum dose: 3 mg/kg/day if inadequate response 1, 8
- Minimum interval between increases: 24 hours 8
High-Risk Populations Requiring Lower Doses (0.5 mg/kg/day)
- Suspected PHACE syndrome 6, 1, 8
- Preterm infants or low birth weight 8
- Infants younger than 4 weeks 8
- Comorbidities increasing hypoglycemia risk 8
- Progressive ulceration while on therapy 6, 8
- Sleep disturbances or other adverse effects 6, 8
Critical Pediatric Administration Rules
- Always administer with or after feeding to prevent hypoglycemia 6, 1, 8
- Hold doses during diminished oral intake or vomiting 6, 1, 8
- For PHACE syndrome: Administer 3 times daily to minimize abrupt blood pressure changes 6, 8
- Duration: Continue until at least 12 months of age, ideally 12-15 months to minimize rebound growth 6
Mandatory Pre-Treatment Assessment
Absolute Contraindications (Do Not Use)
- Second or third-degree heart block 2, 1
- Decompensated heart failure 2, 1
- Asthma or obstructive airway disease 2, 1
- Cardiogenic shock 2, 1
- Sinus node dysfunction without pacemaker 2
- Severe bradycardia or hypotension 1
Required Baseline Evaluation
- Cardiovascular: Heart rate and blood pressure measurement, cardiovascular examination with auscultation 2, 1
- ECG and echocardiogram: Only needed in patients with suspected cardiac abnormalities or segmental head/neck hemangiomas (pediatrics) 1, 8
- Routine labs: NOT required in otherwise healthy adults (no CBC, renal, liver, thyroid function needed) 2
- Screen for: History of bronchospasm, diabetes, concurrent medications affecting cardiac conduction 2
High-Risk Pediatric Monitoring
- Admission required: 2-4 hours on initiation and for dose increments >0.5 mg/kg/day 8
- Vital signs: Measure heart rate and blood pressure before first dose and every 30 minutes for 2-4 hours after first dose 8
- Blood glucose: Only monitor in patients at risk for hypoglycemia 8
Special Populations
Elderly Patients
- Start lower: 40 mg twice daily or 80 mg extended-release initially 1
- Titrate gradually: Increased sensitivity to beta-blockers requires slower titration 1
Diabetic Patients
- Major warning: Propranolol masks hypoglycemia symptoms 2
- Use with extreme caution in patients with diabetes or history of hypoglycemic episodes 2
Critical Safety Principles
Never Abruptly Discontinue
- Taper gradually over several weeks when stopping 2, 1
- Risk of abrupt cessation: Rebound hypertension, tachycardia, or angina 2, 1
- Exception: Safe to stop abruptly in infantile hemangiomas (though rebound growth may occur) 8
Monitoring During Treatment
- Watch for: Hypotension, bradycardia, especially during dose escalation 2, 1
- Signs of excessive beta-blockade: Dizziness, extreme fatigue, syncope 1
- Routine monitoring: Not required between appointments if patient stable and asymptomatic 2
Drug Interactions to Avoid
- Never combine routinely with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 2, 1
Common Pitfalls
Dosing Errors
- Pediatric formulation: Use 5 mg/5 mL preparation to minimize dosing errors 8
- Insufficient dosing in angina: Many trials use suboptimal fixed doses; variable dosing to heart rate target (55-60 bpm) produces superior results 3
Timing Issues
- Rebound growth in hemangiomas: Most likely if discontinued before 12 months of age, especially before 9 months 6, 8
- Risk factors for rebound: Mixed or deep morphology, female sex 6