What is the recommended dosing for propranolol (beta-blocker)?

Propranolol Dosing Recommendations

For most adult indications, start propranolol immediate-release at 80 mg daily in 2 divided doses (or 80 mg once daily extended-release), titrating to a maintenance dose of 120-160 mg daily, with maximum doses up to 640 mg daily if needed. 1, 2, 3

Standard Adult Dosing by Indication

Hypertension

• Initial dose: 80 mg extended-release once daily OR 80 mg immediate-release divided into 2 doses 1, 2, 3
• Maintenance dose: 120-160 mg once daily (extended-release) 1, 2
• Maximum dose: 640 mg daily if adequate blood pressure control is not achieved 1, 3
• Time to full hypertensive response ranges from days to several weeks 3

Angina Pectoris

• Initial dose: 80 mg extended-release once daily 3
• Titration: Increase gradually at 3-7 day intervals until optimal response 3
• Average optimal dose: 160 mg once daily 3
• Maximum dose: 320 mg daily (safety and efficacy beyond this not established) 3
• Older research suggests optimal dosing for moderate-to-severe angina may be 500-800 mg daily, similar to hypertension requirements 4

Anxiety and Physical Symptoms

• Initial dose: 30-60 mg daily in divided doses or as single dose with long-acting formulations 1, 2
• Situational anxiety: 10-40 mg three or four times daily minimizes side effects 2
• Performance anxiety: Single dose of 10-20 mg taken 30-60 minutes before anxiety-provoking event (maximum 40 mg) 1
• Most effective for patients with somatic symptoms (tremor, palpitations, tachycardia, sweating) rather than psychological symptoms 1

Migraine Prophylaxis

• Initial dose: 80 mg extended-release once daily 3
• Usual effective range: 160-240 mg once daily 3
• Discontinue if no satisfactory response within 4-6 weeks after reaching maximal dose 3

Hypertrophic Subaortic Stenosis

• Usual dosage: 80-160 mg extended-release once daily 3

Post-Myocardial Infarction

• Initiation timing: 5-21 days post-MI 2
• Maintenance dose: 180-240 mg daily based on serum drug levels 2
• Results in 26% reduction in all-cause mortality 2

Pediatric Dosing (Infantile Hemangiomas)

• Starting dose: 1 mg/kg/day divided into 2-3 doses with food 2
• Target maintenance: 2-3 mg/kg/day divided into multiple daily doses 2
• Maximum dose: 3 mg/kg/day if inadequate response 2
• Special consideration for PHACE syndrome: Start at 0.5 mg/kg/day divided into 3 doses to minimize abrupt blood pressure changes 2
• Duration: Continue until at least 12 months of age, ideally 12-15 months to minimize rebound growth 2

Special Populations

Elderly Patients

• Start at lower doses (40 mg twice daily or 80 mg extended-release) and titrate more gradually due to increased sensitivity to beta-blockers and altered pharmacokinetics 1, 2

Patients with Comorbidities

• Lower doses may be required for those experiencing adverse effects 1

Mandatory Pre-Treatment Assessment

Screen for absolute contraindications before initiating: 1, 2

• Second or third-degree heart block
• Decompensated heart failure
• Asthma or obstructive airway disease
• Cardiogenic shock
• Sinus node dysfunction without pacemaker
• Severe bradycardia or hypotension

Baseline cardiovascular assessment should include: 1, 2

• Heart rate and blood pressure measurement
• Cardiovascular examination with auscultation
• Screening for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
• ECG and echocardiogram only in patients with suspected cardiac abnormalities or segmental head/neck hemangiomas (pediatric cases) 2

Note: Routine blood work (CBC, renal, liver, thyroid function) is not required before starting propranolol in otherwise healthy adults 1

Critical Administration Principles

Food Administration

• Always administer with food to reduce hypoglycemia risk, particularly important in pediatric patients 1, 2
• Hold doses during diminished oral intake or vomiting 1, 2

Discontinuation Protocol

• Never abruptly discontinue propranolol after chronic use 1, 2
• Taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 2

Monitoring During Treatment

• Monitor for hypotension and bradycardia, especially during dose escalation 1, 2
• Watch for signs of excessive beta-blockade: dizziness, extreme fatigue, syncope 2
• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
• Temporarily discontinue if patient develops wheezing requiring treatment 1

Common Pitfalls and Safety Warnings

Metabolic Considerations

• Propranolol masks symptoms of hypoglycemia in diabetic patients—use with extreme caution in patients with diabetes or history of hypoglycemic episodes 1

Drug Interactions

• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1

Formulation Switching

• Extended-release capsules are not a simple mg-for-mg substitute for immediate-release tablets 3
• Extended-release produces lower blood levels and has different kinetics 3
• Retitration may be necessary when switching formulations, especially to maintain effectiveness at the end of the 24-hour dosing interval 3

Dosing Frequency

• Research demonstrates that twice-daily dosing provides equivalent beta-blockade to three-times-daily dosing at the same total daily dose, with higher trough levels favoring twice-daily administration 5, 6
• Plasma propranolol levels above 20 ng/ml induce significant beta-blockade, typically achieved with daily doses slightly exceeding 160 mg 6