Propranolol Dosing for Palpitations
For palpitations with normal thyroid function, start propranolol immediate-release at 10-40 mg three to four times daily (not once daily), or alternatively use the long-acting formulation at 80 mg once daily. 1
Dosing Regimens
Immediate-Release Formulation
- Start with 10-40 mg three to four times daily (total daily dose 30-160 mg), titrating based on symptom control and heart rate response 1
- The immediate-release half-life is only 3-6 hours, which is why multiple daily doses are required 2
- For palpitations specifically, typical dosing is 3-4 times daily, not once daily 2
- Alternative twice-daily dosing (80-160 mg total daily in 2 divided doses) is acceptable for certain indications like hypertension, but less ideal for palpitations 2
Long-Acting Formulation (If Preferred)
- Start at 80 mg once daily, titrating to 120-160 mg once daily for maintenance 2, 1
- The extended-release half-life is 8-20 hours, allowing once-daily dosing 2
- The FDA label specifies that extended-release capsules are not a simple mg-for-mg substitute for immediate-release tablets and may require retitration 3
Mandatory Pre-Treatment Assessment
Before prescribing propranolol, you must screen for absolute contraindications 2, 1:
- Second or third-degree heart block 2
- Decompensated heart failure or significant left ventricular dysfunction 2
- Asthma or obstructive airway disease 2, 1
- Cardiogenic shock or hypotension 2, 1
- Sinus node dysfunction without a pacemaker 2
Perform baseline assessment including 2:
- Heart rate and blood pressure measurement
- 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 2, 1
- In diabetic patients, counsel that propranolol may mask hypoglycemia symptoms 2, 1
- No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic 2
Critical Safety Warnings
Discontinuation
- Never abruptly discontinue propranolol after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 2, 1
Drug Interactions
- Avoid combining with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block 2, 1
Common Pitfalls
- Do not use weight-based dosing in adults—use fixed-dose ranges as specified 1
- Elderly patients may require lower doses due to altered pharmacokinetics 2, 1
- Hold doses during times of diminished oral intake or vomiting to reduce hypoglycemia risk 2
Acute Settings
For rapid effect in acute situations, IV propranolol can be given as 1 mg over 1 minute, repeated every 2 minutes as needed, up to 3 doses 2, 1