What is the appropriate dosing of propranolol (beta-blocker) for an adult patient with palpitations, without significant cardiovascular comorbidities or contraindications to beta-blocker therapy?

Propranolol 10 mg TID for Palpitations

For palpitations without significant cardiovascular comorbidities, propranolol 10 mg three times daily is a reasonable starting dose, but most patients will require titration to 80-160 mg daily in divided doses for optimal symptom control. 1

Initial Dosing Strategy

• Start with propranolol immediate-release 10-20 mg three times daily for patients with palpitations and prominent somatic symptoms of autonomic hyperactivity (tremor, palpitations, sweating). 1
• The immediate-release formulation has a half-life of 3-6 hours, necessitating multiple daily doses for sustained effect. 1
• Your current dose of 10 mg TID (30 mg total daily) is below the typical therapeutic range but appropriate for initial titration. 1

Titration Protocol

• Gradually increase the dose every 3-7 days based on symptom response and tolerability. 2
• The typical effective dose range for palpitations is 80-160 mg daily in 2-4 divided doses (e.g., 40 mg TID or 40 mg BID). 1
• For ongoing symptoms, titrate to 40 mg twice daily (80 mg total daily) initially, with a typical effective range of 80-160 mg daily. 1
• Historical data from hyperkinetic heart syndrome (which presents with palpitations and rapid heart action) showed good symptom control with 80-160 mg/day. 3

Mandatory Pre-Treatment Assessment

Before continuing or increasing propranolol, verify absence of absolute contraindications:

• Second or third-degree heart block (obtain baseline ECG if not already done). 1
• Decompensated heart failure or significant left ventricular dysfunction. 1
• Asthma or obstructive airway disease (auscultate lungs for wheezing). 1
• Hypotension (systolic BP <100 mmHg with symptoms). 1
• Sinus node dysfunction without a pacemaker. 1

Monitoring During Titration

• Check heart rate and blood pressure at each dose increase. 1
• Target resting heart rate is typically 55-60 bpm unless limiting side effects occur. 4
• Monitor for common adverse effects: hypotension, bradycardia, fatigue, dizziness, and cold extremities. 1
• If diabetic, counsel that propranolol masks hypoglycemia symptoms (tremor, tachycardia). 1

Alternative Formulation Option

• Once optimal dose is established, consider switching to propranolol LA (long-acting) 80 mg once daily, titrated to 120-160 mg once daily for convenience. 1, 2
• The extended-release formulation has a half-life of 8-20 hours, allowing once-daily dosing. 1
• Do not consider this a simple mg-for-mg substitute; retitration may be necessary as extended-release produces lower peak blood levels. 2

Critical Safety Warnings

• Never abruptly discontinue propranolol after chronic use, as this can precipitate rebound hypertension, tachycardia, or angina. 1
• When discontinuation is necessary, taper gradually over several weeks. 1
• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block. 1

Expected Outcomes

• Symptom improvement should occur within days to weeks of reaching therapeutic dose. 3
• If no satisfactory response after 4-6 weeks at maximum tolerated dose, consider alternative therapies or cardiology referral. 2
• Most patients with palpitations from hyperkinetic circulation respond well to doses of 80-160 mg daily. 3

Common Pitfalls to Avoid

• Don't assume 10 mg TID is sufficient without attempting dose escalation—this is below the therapeutic range for most patients. 1
• Don't increase doses too rapidly—allow 3-7 days between increases to assess tolerance. 2
• Don't forget to screen for asthma/reactive airway disease before each dose increase, as bronchospasm risk increases with higher doses. 1