What are the uses and dosages of propranolol in various medical conditions?

Uses and Dosages of Propranolol

Cardiovascular Indications

Propranolol is indicated for hypertension, angina pectoris, cardiac arrhythmias, post-myocardial infarction, and hypertrophic cardiomyopathy, with dosing ranging from 80-640 mg daily depending on the specific condition. 1

Hypertension

• Initial dose: 80 mg once daily (extended-release formulation), whether used alone or with a diuretic 1
• Maintenance dose: 120-160 mg once daily 1
• Maximum dose: Up to 640 mg daily may be required in some patients 1
• Time to full hypertensive response varies from days to several weeks 1

Angina Pectoris

• Starting dose: 80 mg once daily (extended-release) 1
• Optimal dose: Average of 160 mg once daily 1
• Maximum dose: Safety and efficacy beyond 320 mg daily have not been established 1
• Dosage should be increased gradually at 3-7 day intervals until optimal response 1
• Gradual discontinuation is mandatory over several weeks to prevent rebound angina 1, 2

Cardiac Arrhythmias

• Ventricular tachycardia and PVCs: Propranolol is used for rate control, particularly when sympathetic tone is elevated 2
• Atrial fibrillation: Propranolol provides rate control through slowing of sinus rate and increased AV nodal refractoriness 2
• IV dosing for acute situations: 1-3 mg every 5 minutes to a total of 5 mg 2
• Oral immediate-release: 10-40 mg every 6 hours 2
• Oral extended-release: 60-160 mg every 12 hours 2

Hypertrophic Cardiomyopathy

• Propranolol was the first drug used for medical management of HCM and remains effective for symptomatic patients, particularly those with exertional gradients. 2
• Dosage range: Up to 480 mg per day (2 mg/kg in children) 2
• Beta-blockers mitigate symptoms by decreasing heart rate, prolonging diastole, reducing LV contractility, and possibly reducing microvascular ischemia 2
• Most beneficial for patients with outflow gradients present only during exertion 2
• Potential side effects include fatigue, impotence, sleep disturbances, and chronotropic incompetence 2

Post-Myocardial Infarction

• Propranolol is indicated for secondary prevention after MI 3
• Reduces post-MI mortality 3

Neurological and Psychiatric Indications

Migraine Prophylaxis

• Initial dose: 80 mg once daily (extended-release) 1
• Effective range: 160-240 mg once daily 1
• Dosage may be increased gradually to achieve optimal prophylaxis 1
• If no response within 4-6 weeks at maximal dose, discontinue therapy 1
• Gradual withdrawal over several weeks is advisable depending on patient age, comorbidity, and dose 1

Anxiety Disorders

• For situational/performance anxiety: 10-20 mg taken 30-60 minutes before the anxiety-provoking event 4
• Maximum single dose for situational use: 40 mg 4
• For ongoing anxiety: Initial dose of 40 mg twice daily (80 mg total daily), with typical effective range of 80-160 mg daily in 2 divided doses 4
• Long-acting formulation: 80 mg once daily, titrated to 120-160 mg once daily 4
• Most effective for patients with prominent somatic symptoms (tremor, palpitations, tachycardia, sweating) rather than psychological symptoms 4

Essential Tremor

• Propranolol is effective for essential tremor management 3

Endocrine Indications

Hyperthyroidism

• Propranolol is used to control symptoms of hyperthyroidism 3

Pheochromocytoma

• Propranolol has a role in pheochromocytoma management 3

Dermatologic Indication

Infantile Hemangiomas (IH)

• Propranolol is the treatment of choice for IHs requiring systemic therapy, replacing corticosteroids as the gold standard. 2
• Dosing: 2-3 mg/kg per day unless comorbidities (e.g., PHACE syndrome) or adverse effects necessitate lower doses 2
• FDA-approved dosing: Starting dose of 0.6 mg/kg twice daily, gradually increased over 2 weeks to maintenance dose of 1.7 mg/kg twice daily (3.4 mg/kg per day) 2
• Regimen of 3 mg/kg per day for 6 months showed superior results: Complete or nearly complete resolution in 60% of patients versus 4% with placebo 2
• Administer with or after feeding; hold doses during diminished oral intake or vomiting 2

Other Indications

Portal Hypertension

• Propranolol is used in the management of portal hypertension 3

Hypertrophic Subaortic Stenosis

• Usual dosage: 80-160 mg once daily (extended-release) 1

Critical Safety Considerations Across All Indications

Absolute Contraindications

• Second or third-degree heart block 4
• Decompensated heart failure 4
• Asthma or obstructive airway disease 4
• Cardiogenic shock 4
• Sinus node dysfunction without pacemaker 4
• Hypotension 4

Pre-Treatment Assessment

• Baseline cardiovascular assessment recommended: Heart rate and blood pressure measurement, cardiovascular examination with auscultation 4
• Screen for: History of bronchospasm, diabetes, concurrent medications affecting cardiac conduction 4
• For infantile hemangiomas: Consider ECG in younger infants, those with low heart rate, or abnormal cardiac examination 4

Monitoring Requirements

• Monitor for hypotension and bradycardia, especially during dose escalation 4
• Common adverse effects: Fatigue, bradycardia, hypotension, dizziness, cold extremities, sleep disturbances, potential worsening of heart failure 4
• In diabetic patients: Propranolol masks symptoms of hypoglycemia 2, 4

Discontinuation Protocol

• Never abruptly discontinue propranolol after chronic use 4
• Gradual taper over 1-3 weeks is mandatory to prevent rebound hypertension, tachycardia, or angina 4

Drug Interactions

• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 4

Special Populations

• Elderly patients may require lower doses due to altered pharmacokinetics 4
• In children: Monitor closely for effects on growth and school performance; may trigger depression in children and adolescents 2
• Alcohol consumption: Consider lower starting doses (10-20 mg three times daily) and three-times-daily dosing for more consistent blood levels 5
• Liver disease: Dosage may need reduction due to decreased drug clearance 5