What is the recommended propranolol (beta-blocker) titration dose per week for an adult patient?

Propranolol Titration for Adults

For most adult indications, start propranolol at 80 mg daily (immediate-release divided twice daily or long-acting once daily) and increase by 40-80 mg increments at 3-7 day intervals until optimal response is achieved, with typical maintenance doses of 120-160 mg daily. 1, 2, 3

Initial Dosing Strategy

• Start with 80 mg daily: Either 40 mg twice daily of immediate-release formulation or 80 mg once daily of long-acting formulation 1, 3
• For hypertension specifically, the FDA-approved starting dose is 80 mg once daily of extended-release formulation 3
• For anxiety treatment, begin with 40 mg twice daily (80 mg total daily) of immediate-release propranolol 1

Titration Schedule

Increase dosage at 3-7 day intervals until adequate therapeutic response is achieved 2, 3:

• Week 1: 80 mg daily (baseline dose)
• Week 2-3: Increase to 120-160 mg daily if needed
• Subsequent weeks: Continue increasing by 40-80 mg increments every 3-7 days as tolerated

The American College of Cardiology emphasizes that the time needed for full therapeutic response is variable and may range from a few days to several weeks, so patience during titration is essential 1

Target Maintenance Doses by Indication

• Hypertension: 120-160 mg once daily (maximum 640 mg daily if needed) 1, 3
• Anxiety: 80-160 mg daily in 2 divided doses, or 120-160 mg once daily of long-acting formulation 1
• Angina: Average optimal dose is 160 mg once daily, though doses up to 320 mg daily may be used 3
• Migraine prophylaxis: 160-240 mg once daily 3

Critical Pre-Treatment Assessment

Before initiating propranolol, the American Heart Association mandates screening for absolute contraindications 1:

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

Obtain baseline heart rate and blood pressure before starting therapy 1, 4

Monitoring During Titration

• Monitor for hypotension and bradycardia, especially during dose escalation 1
• Hold doses if heart rate falls below 55-60 bpm or if symptomatic hypotension occurs
• No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic 1

Special Populations Requiring Dose Adjustment

Elderly patients may require lower doses due to altered pharmacokinetics 1

Patients with severe liver disease (serum albumin <30 g/L) should start with much lower doses (20 mg three times daily of immediate-release or 80 mg daily of slow-release) and require hospital initiation with careful heart rate monitoring 5

Critical Safety Warnings

Never abruptly discontinue propranolol after chronic use—this can precipitate rebound hypertension, tachycardia, or angina 1, 2, 3. When discontinuing, taper gradually over several weeks 1, 2

Common pitfalls to avoid:

• Propranolol masks symptoms of hypoglycemia in diabetic patients—use with extreme caution 1, 4
• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1
• Extended-release formulations are not mg-for-mg substitutes for immediate-release—retitration may be necessary 3

Practical Titration Algorithm

1. Screen for contraindications and obtain baseline vitals 1, 4
2. Start 80 mg daily (divided or once daily depending on formulation) 1, 3
3. Assess response at 3-7 days: Check heart rate, blood pressure, and symptom control 2, 3
4. If inadequate response and no adverse effects: Increase by 40-80 mg 2
5. Repeat assessment every 3-7 days until optimal response achieved 2, 3
6. Typical effective range: 120-160 mg daily for most indications 1, 3
7. Maximum doses: Up to 320-640 mg daily depending on indication, though most patients respond to lower doses 1, 3

Research evidence supports that relatively low doses (80-160 mg daily) induce most of the therapeutic effect, with diminishing returns at higher doses 6. Approximately 50% of patients achieve adequate beta-blockade with 160 mg daily 7.