Propranolol Dosing for Essential Tremor
Start propranolol at 40 mg twice daily (80 mg/day total) using immediate-release formulation, or 80 mg once daily using long-acting formulation, and titrate up to 120-240 mg/day for optimal tremor control, as this dose range achieves therapeutic plasma levels while minimizing side effects. 1, 2
Initial Dosing Strategy
- Begin with propranolol immediate-release 80 mg daily in 2 divided doses (40 mg twice daily), or propranolol long-acting 80 mg once daily 1
- Titrate upward to 120-160 mg daily for maintenance dosing based on tremor response 1
- The therapeutic sweet spot for essential tremor occurs at relatively low plasma propranolol levels, achieved with daily doses of 120-240 mg 2
- Maximum doses up to 640 mg daily may be used if needed, though most patients respond at lower doses 1
Evidence Supporting This Dosing
- Classic studies demonstrate that 120 mg/day effectively reduces tremor in all treated patients, with most pronounced improvement in upper extremities 3
- Lower doses (80 mg/day) show significant tremor reduction within one week of treatment 4
- Optimal tremor relief occurs at plasma concentrations below 20-40 ng/ml, which corresponds to daily doses of 120-240 mg 2
- Doses of 80-160 mg/day provide long-term efficacy in the majority of patients 5
Mandatory Pre-Treatment Assessment
Screen for absolute contraindications before initiating therapy: 1, 6
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or obstructive airway disease
- Cardiogenic shock
- Sinus node dysfunction without pacemaker
- History of hypoglycemic episodes
Perform baseline cardiovascular assessment: 1, 6
- Measure heart rate and blood pressure
- Cardiovascular examination with auscultation
- Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
Monitoring During Treatment
- Monitor for hypotension and bradycardia, especially during dose escalation 1, 6
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
- Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities 1
Critical Safety Considerations
- Never abruptly discontinue propranolol—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 6
- Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1, 6
- Propranolol masks symptoms of hypoglycemia in diabetic patients—use with extreme caution in this population 1
- Administer with food to reduce risk of hypoglycemia, and hold doses during diminished oral intake or vomiting 1
Expected Outcomes and Limitations
- Approximately 30% of patients may have no therapeutic benefit from propranolol 5
- Tolerance to drug effect occurs in about 12.5% of patients with chronic treatment 5
- Significant chronic side effects occur in 17% of patients, which may necessitate dose reduction or discontinuation 5
- Tremor improvement varies widely among individuals (mean 51%, range 25-90%) 2