What is the typical dose of propranolol (beta-blocker) for managing palpitations?

Propranolol Dosing for Palpitations

For symptomatic palpitations, start propranolol at 10-40 mg three to four times daily (immediate-release) or 80 mg once daily (extended-release), titrating upward based on symptom control and heart rate response. 1

Immediate-Release Formulation

• Initial dosing: Start with 10-40 mg administered 3-4 times daily for symptomatic control of palpitations 1
• Intravenous option for acute settings: If rapid control is needed, administer 0.5-1 mg over 1 minute, which can be repeated up to a total dose of 0.1 mg/kg (approximately 1 mg per dose, up to 3 doses) 1
• The IV formulation has an onset of action within 5 minutes 1
• Oral immediate-release propranolol has a half-life of 3-6 hours, necessitating multiple daily doses 1

Extended-Release Formulation

• Initial dosing: Begin with 80 mg once daily of the extended-release capsule 2
• Titration: The dose may be increased gradually, with typical maintenance ranging from 80-160 mg once daily 2
• Extended-release formulations have a half-life of 8-20 hours, allowing for once-daily administration 1
• Important caveat: Extended-release capsules are not mg-for-mg equivalent to immediate-release tablets due to different pharmacokinetics and lower blood levels; retitration may be necessary 2

Dosing Strategy Based on Underlying Rhythm

For Atrial Fibrillation-Related Palpitations

• Target a resting heart rate <80 bpm for symptomatic patients 3
• Oral maintenance typically requires 25-100 mg twice daily of immediate-release metoprolol (a comparable beta-blocker), suggesting propranolol doses in the 80-240 mg daily range divided into multiple doses would be appropriate 1, 3

For Ventricular Ectopy-Related Palpitations

• Higher doses are often required for arrhythmia suppression beyond simple beta-blockade 4, 5
• Effective antiarrhythmic doses typically range from 200-640 mg daily, with some patients requiring up to 960 mg daily 5
• Only one-third of patients with ventricular arrhythmias respond to doses ≤160 mg/day, while an additional 40% respond at 200-640 mg/day 5

Titration and Monitoring

• Gradual escalation: Increase the dose every 3-7 days based on symptom response and tolerability 2
• Beta-blockade assessment: Near-maximal beta-receptor blockade is achieved at serum concentrations around 150 ng/ml, corresponding to doses that reduce exercise-induced tachycardia by approximately 25-30% 4, 6
• Higher concentration effects: Some patients require serum concentrations >500 ng/ml for optimal antiarrhythmic efficacy, suggesting direct membrane-stabilizing effects beyond beta-blockade 4, 5
• Monitor for symptomatic bradycardia, which may require dose reduction or permanent pacing 1

Important Contraindications and Precautions

• Absolute contraindications: Asthma, decompensated heart failure, and pre-excited atrial fibrillation (as in Wolff-Parkinson-White syndrome) 1, 3
• Starting low in heart failure risk: Begin with the lowest dose even if higher doses are anticipated, as the greatest risk of precipitating heart failure occurs when initiating therapy, not when increasing established doses 7
• Gradual discontinuation: If stopping propranolol, taper gradually over several weeks to avoid rebound tachycardia or worsening symptoms 2

Common Pitfalls

• Underdosing: Many clinicians stop at 80-160 mg daily, but palpitations from ventricular ectopy often require 400-800 mg daily for optimal control 7, 5
• Premature discontinuation: Allow 4-6 weeks at maximum tolerated dose before declaring treatment failure 2
• Biphasic response: Approximately 15% of patients show a biphasic dose-response curve where arrhythmias initially improve but then worsen with further dose escalation; if symptoms worsen after dose increase, reduce to the previous effective dose 5