What is the recommended dosage of Propanolol for a patient with hypertension or angina?

Propranolol Dosing for Hypertension and Angina

For hypertension, start propranolol immediate-release at 80-160 mg daily divided into 2 doses (40-80 mg twice daily), or propranolol long-acting at 80 mg once daily, titrating up to 120-160 mg daily for maintenance. 1, 2 For angina pectoris, the optimal therapeutic dose averages 500-800 mg daily in divided doses, though starting lower and titrating upward is essential for safety. 3

Hypertension Dosing

Immediate-Release Formulation:

• Starting dose: 80-160 mg daily divided into 2 doses (administered twice daily) 1, 2
• Maintenance dose: Up to 100 mg twice daily 4
• Maximum dose: 640 mg daily if needed 1

Long-Acting Formulation:

• Starting dose: 80 mg once daily 1, 2
• Maintenance dose: Titrate to 120-160 mg once daily 1
• The long-acting formulation has a terminal half-life of 8-11 hours, allowing once-daily dosing with sustained beta-blockade throughout 24 hours 5

Angina Pectoris Dosing

The evidence strongly supports higher doses for angina than traditionally used:

• Starting dose: 40 mg three to four times daily (160 mg total daily) 6, 3
• Optimal therapeutic dose: Average 500-800 mg daily in divided doses for moderate to severe angina 3
• Studies demonstrate a dose-dependent anti-anginal effect, with progressive reduction in angina attacks as dosage increases logarithmically up to 417 mg daily 3
• Maximum therapeutic benefit occurs at plasma propranolol concentrations of 30±7 ng/ml, corresponding to 64-98% of total beta-blockade 7

Alternative long-acting regimen:

• Propranolol LA 160 mg daily is as effective as conventional propranolol 40 mg four times daily for exercise tolerance, ST-segment depression, angina attack rate, and nitroglycerin consumption 6

Critical Pre-Treatment Assessment

Absolute contraindications that must be excluded: 4, 1, 2

• Second or third-degree heart block without functioning pacemaker
• Decompensated heart failure (presence of rales or S3 gallop)
• Asthma or severe obstructive airway disease
• Cardiogenic shock or high risk for shock
• Severe bradycardia (heart rate <50 bpm)
• Hypotension (systolic BP <90 mmHg)
• Sinus node dysfunction without pacemaker

Baseline assessment required: 1, 2

• Heart rate and blood pressure measurement
• Cardiovascular examination with auscultation for rales and bronchospasm
• ECG only if cardiac symptoms, abnormal heart rate, or family history of sudden death present 2
• Screen for history of diabetes (propranolol masks hypoglycemia symptoms) 4, 1

Dosing Principles and Titration

Start low and titrate gradually to avoid precipitating heart failure:

• The greatest risk of heart failure occurs when initiating treatment, even with small starting doses 3
• Once treatment has begun, dosage can be increased more aggressively as the heart has adapted to beta-blockade 3
• For angina, adjust dosage to achieve resting heart rate of 55-60 bpm unless limited by side effects 4, 3

Administration guidelines:

• Immediate-release: Administer 2-4 times daily for most indications 1
• Twice daily dosing is acceptable for hypertension despite 3-6 hour half-life 1
• Long-acting: Once daily dosing provides sustained therapeutic levels 1, 5

Acute/IV Dosing for Unstable Angina/NSTEMI

For acute settings requiring rapid effect: 4, 1

• IV propranolol: 0.5-1.0 mg initially, followed in 1-2 hours by 40-80 mg orally every 6-8 hours 4
• Alternative IV regimen: 1 mg over 1 minute, repeated every 2 minutes as needed, up to 3 doses (IV half-life 2.4 hours) 1
• Transition to oral: After tolerating 15 mg IV total (5 mg increments over 15 minutes), start oral therapy at 25-50 mg every 6 hours for 48 hours, then increase to maintenance dose 4

Patients who should NOT receive acute beta-blockade: 4

• Marked first-degree AV block (PR interval >0.24 seconds)
• Evidence of low-output state (oliguria)
• Sinus tachycardia reflecting low stroke volume
• Killip Class II or III (highest risk for cardiogenic shock)

Critical Safety Warnings

Never abruptly discontinue propranolol after chronic use:

• Abrupt withdrawal causes rebound hypertension, tachycardia, angina, and enhanced beta-adrenergic sensitivity 1, 2, 8
• Taper gradually over several weeks when discontinuing 1, 2
• Prolonged small dose therapy (30 mg daily for 2 weeks) before complete withdrawal prevents cardiac hypersensitivity and adverse withdrawal events 8

Monitor for adverse effects during titration: 1

• Hypotension and bradycardia, especially during dose escalation
• Fatigue, dizziness, cold extremities
• Worsening heart failure (auscultate for rales)
• Bronchospasm in patients with reactive airway disease

Drug interactions to avoid: 1

• Do not routinely combine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block

Special Populations

Elderly patients: 1, 2

• Start at lower doses (40 mg twice daily or 80 mg extended-release)
• Titrate more gradually due to increased sensitivity to beta-blockers

Patients with diabetes: 4, 1

• Use with extreme caution as propranolol masks hypoglycemia symptoms
• Consider cardioselective beta-blockers as alternative

Patients with mild COPD or history of bronchospasm: 4

• Use low doses of cardioselective agent (metoprolol 12.5 mg orally) rather than complete avoidance
• Mild wheezing mandates short-acting cardioselective agent at reduced dose