Propranolol Dosing Guidelines

Standard Adult Dosing by Indication

For hypertension and angina, start with propranolol immediate-release 80 mg daily in 2 divided doses (40 mg twice daily), or propranolol extended-release 80 mg once daily, titrating to a maintenance dose of 120-160 mg daily, with a maximum of 640 mg daily if needed. 1

Hypertension

Immediate-release: 80-160 mg daily divided into 2 doses 2
Extended-release: 80 mg once daily, titrating to 120-160 mg once daily 1
Maximum dose: 640 mg daily 2

Angina Pectoris

Start with 80 mg daily in divided doses or as extended-release 1
Average optimal dosage for moderate-to-severe angina: 500-800 mg daily 3
Titrate based on symptom control and heart rate response 3

Essential Tremor

Therapeutic range: 80-240 mg daily, with most patients responding within this range 1
Start at lower end and titrate upward based on tremor response 1
Patients with smaller tremor amplitude (<0.006 cm hand displacement) show less satisfactory response 4
A single 120 mg dose can produce rapid tremor reduction of approximately 43% 4

Migraine Prophylaxis

Start with 80 mg daily in divided doses 1
Titrate to 160-240 mg daily for maintenance 1

Performance-Related Anxiety (Situational)

For acute situational anxiety: 10-40 mg taken 30-60 minutes before the anxiety-provoking event 2
Single dose: 10-20 mg is typically sufficient 2
Maximum single dose: 40 mg 2
This is specifically for performance anxiety with prominent somatic symptoms (tremor, palpitations, sweating), not for chronic generalized anxiety 2

Chronic Anxiety with Physical Symptoms

Start with 40 mg twice daily (80 mg total daily) of immediate-release formulation 2
Typical effective range: 80-160 mg daily in 2 divided doses 2
Extended-release alternative: 80 mg once daily, titrating to 120-160 mg once daily 2
Propranolol is most effective for patients with autonomic hyperactivity symptoms (tremor, palpitations, tachycardia, sweating) rather than predominantly psychological anxiety 2

Supraventricular Tachycardia (Ongoing Oral Therapy)

Start with 30-60 mg daily in divided doses or as single dose with long-acting formulations 5
Maximum maintenance: 40-160 mg daily in divided or single dose with long-acting formulations 5

Pediatric Dosing (Primarily for Infantile Hemangiomas)

For infantile hemangiomas, start with 1 mg/kg/day divided into 2-3 doses administered with food, titrating to a target maintenance dose of 2-3 mg/kg/day. 1

Standard Pediatric Dosing

Starting dose: 1 mg/kg/day divided into 2-3 doses 1, 6
Maintenance dose: 2 mg/kg/day for uncomplicated patients 6
Maximum dose: 3 mg/kg/day for non-responders 6
Most studies support 2-3 mg/kg/day for optimal efficacy 6

Special Pediatric Populations Requiring Lower Starting Doses (0.5 mg/kg/day)

Suspected PHACES syndrome (administer 3 times daily to minimize abrupt blood pressure changes) 1, 6
Preterm infants or low birth weight 6
Infants younger than 4 weeks of age 6
Patients with comorbidities increasing hypoglycemia risk 6
Patients with progressive ulceration while on therapy 6

Pediatric Administration Guidelines

Always administer with or after feeding to prevent hypoglycemia 1, 2
Hold doses during diminished oral intake or vomiting 1, 2
Minimum interval between dose increases: 24 hours 6
Continue treatment until at least 12 months of age, ideally 12-15 months to minimize rebound growth 1
Use 5 mg/5 mL preparation to minimize dosing errors 6

Pediatric Monitoring Requirements

High-risk patients require admission for 2-4 hours on initiation and for dose increments >0.5 mg/kg/day 6
Measure heart rate and blood pressure before first dose and every 30 minutes for 2-4 hours after first dose in high-risk patients 6
Blood glucose monitoring only needed in patients at risk for hypoglycemia 6

Dose Adjustments for Special Populations

Elderly Patients

Start at lower doses (40 mg twice daily or 80 mg extended-release) and titrate more gradually due to increased sensitivity to beta-blockers 1
Elderly patients may require lower maintenance doses due to altered pharmacokinetics 2

Hepatic Impairment

Propranolol undergoes extensive hepatic metabolism with dose-dependent bioavailability 7
Dose adjustment required in hepatic impairment 7
Start at lower doses and monitor closely for signs of excessive beta-blockade 1

Renal Impairment

Propranolol does not require dose adjustment for renal impairment (unlike atenolol and nadolol which do) 7
Age, gender, race, and ethnicity do not significantly alter propranolol pharmacokinetics 7

Formulation Differences and Pharmacokinetics

Immediate-Release Formulation

Half-life: 3-6 hours 2
Dosing frequency: 2-4 times daily for most indications 2
Twice daily acceptable for hypertension 2
Time to peak: shorter, with higher peak concentrations 8

Extended-Release (Long-Acting) Formulation

Half-life: 8-20 hours 2, 8
Dosing frequency: once daily 2
Bioavailability 30-50% less than immediate-release due to increased hepatic metabolism 8
Lower peak concentrations with delayed time to peak 8
Maintains relatively constant plasma levels throughout 24-hour dosing interval 8

Intravenous Formulation (Acute Settings)

Dose: 1 mg over 1 minute 2
May repeat every 2 minutes as needed, up to 3 doses 2
Half-life: 2.4 hours 2

Mandatory Pre-Treatment Assessment

Before initiating propranolol, screen for absolute contraindications including second or third-degree heart block, decompensated heart failure, asthma/obstructive airway disease, cardiogenic shock, sinus node dysfunction without pacemaker, and severe bradycardia or hypotension. 1, 2

Baseline Cardiovascular Assessment

Measure heart rate and blood pressure 1, 2
Perform cardiovascular examination with auscultation 2
ECG and echocardiogram only in patients with suspected cardiac abnormalities, segmental head/neck hemangiomas, abnormal heart rate for age, strong family history of sudden death or arrhythmia, episodes of loss of consciousness, or maternal history of connective tissue disease 1, 2
Routine blood work (CBC, renal, liver, thyroid function) not required in otherwise healthy adults 2

Additional Screening

History of bronchospasm or reactive airway disease 2
Diabetes or history of hypoglycemic episodes 2
Concurrent medications affecting cardiac conduction or CYP metabolism 2
Screen for relative contraindications: hypotension, concurrent use of non-dihydropyridine calcium channel blockers 2

Absolute Contraindications

Second or third-degree heart block (without pacemaker) 5, 1, 2
Decompensated heart failure or severe left ventricular dysfunction 5, 1, 2
Asthma or obstructive airway disease (non-selective β-blockade can precipitate life-threatening bronchospasm) 5, 1, 2
Cardiogenic shock 5, 2
Sinus node dysfunction or sinus bradycardia (without pacemaker) 5, 2
Severe hypotension 5, 1

Critical Safety Considerations and Monitoring

Gradual Discontinuation Required

Never abruptly discontinue propranolol after chronic use; taper gradually over 1-3 weeks to prevent rebound hypertension, tachycardia, or angina 1, 2
Abrupt discontinuation can precipitate serious cardiovascular events 2

Administration with Food

Administer propranolol with food to reduce hypoglycemia risk, particularly important in pediatric patients and those with diabetes 1, 2
Hold doses during diminished oral intake or vomiting 1, 2

Monitoring for Excessive Beta-Blockade

Watch for dizziness, light-headedness, or syncope 1, 2
Monitor for marked fatigue 1, 2
Heart rate falling below 50 beats/minute 2
Systolic blood pressure dropping below 90 mmHg 2
New or worsening shortness of breath or wheezing 2
No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 2

Hypoglycemia Masking

Propranolol masks typical adrenergic warning signs of hypoglycemia (tremor, rapid heartbeat, sweating) 2
Patients with diabetes or history of hypoglycemia should monitor blood glucose more frequently 2
Rely on non-adrenergic cues (hunger, confusion, sweating) to detect hypoglycemia 2
Use with extreme caution in diabetic patients 2

Temporary Discontinuation Indications

Wheezing requiring treatment 2
Significantly reduced oral intake or vomiting 2
Any acute illness interfering with normal oral intake 2

Drug Interactions

Major Interactions to Avoid

Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to markedly increased risk of bradycardia and heart block 5, 2
Propranolol is contraindicated with dofetilide 5

CYP Metabolism

Propranolol is a substrate of CYP2D6, CYP1A2, and CYP2C19 7
Potential pharmacokinetic interactions with co-administered drugs affecting these enzymes 7
Diltiazem and verapamil are CYP3A4 inhibitors, further complicating their combination with propranolol 5

Alternative Beta-Blockers When Propranolol Is Not Suitable

For Patients with Renal Dysfunction

Metoprolol tartrate: 25 mg twice daily, maximum 200 mg twice daily 5
Metoprolol succinate: 50 mg once daily, maximum 400 mg once daily 5
These do not require renal dose adjustment unlike atenolol and nadolol 5

For Patients Requiring Once-Daily Dosing

Atenolol: 25-50 mg once daily, maximum 100 mg once daily (requires reduced dosing in severe renal dysfunction) 5
Nadolol: 40 mg once daily, maximum 320 mg once daily (requires reduced dosing in renal impairment) 5

For Patients with Reactive Airway Disease

Consider cardioselective beta-blockers (metoprolol, atenolol) with extreme caution, though all beta-blockers carry some bronchospasm risk 5
Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) may be alternatives for rate control, though not for tremor or anxiety 5

Common Pitfalls and Caveats

Dosing Errors

Different propranolol formulations (immediate vs. extended-release) require different dosing schedules 2
The 5 mg/5 mL pediatric preparation is least likely to cause dosing errors 6
Do not interchange immediate-release and extended-release formulations without dose adjustment 8

Inadequate Dosing

Many patients receive suboptimal doses; for angina, average optimal dosage is 500-800 mg daily, not the commonly prescribed lower doses 3
For essential tremor, doses below 80 mg daily are often inadequate 1
Patients with small tremor amplitude may show less satisfactory response regardless of dose 4

Inappropriate Use for Chronic Generalized Anxiety

Propranolol is not suitable for chronic generalized anxiety disorder 2
It is most effective for situational anxiety with prominent somatic symptoms 2
Japanese guidelines deprecate propranolol for generalized social anxiety disorder based on negative evidence 2

Rebound Growth in Pediatric Hemangiomas

Discontinuation before 12 months of age, particularly before 9 months, increases risk of rebound growth 6
Treatment should continue until at least 12-15 months of age 1
Guidelines suggest abrupt discontinuation is safe, though gradual taper over 1-3 weeks is recommended 6, 2

Heart Failure Precipitation

Greatest risk of precipitating heart failure is at treatment initiation, even with small starting doses 3
Once treatment has begun, gradual dose increases represent small pharmacological increments and are less likely to precipitate heart failure 3
Start at low doses and titrate gradually, especially in patients with any degree of cardiac dysfunction 3

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