What is the recommended propranolol dosing regimen for an adult with tremor who has no contraindications such as asthma, COPD, high‑grade AV block, uncontrolled heart failure, or severe peripheral vascular disease?

Propranolol Dosing for Tremor

For essential tremor or other tremor syndromes in adults without contraindications, start propranolol immediate-release at 40 mg twice daily (80 mg total daily dose) and titrate upward by 40–80 mg every 1–2 weeks to a typical maintenance range of 120–320 mg daily in divided doses, with a maximum of 640 mg daily if needed. 1

Initial Dosing Strategy

• Begin with propranolol immediate-release 40 mg twice daily (total 80 mg/day), which provides adequate beta-blockade while minimizing initial side effects 1
• The immediate-release formulation has a half-life of 3–6 hours, requiring multiple daily doses to maintain therapeutic effect 2, 3
• Alternatively, start propranolol long-acting 80 mg once daily if adherence to multiple daily doses is a concern; the extended-release formulation has a half-life of 8–20 hours 1, 3

Titration Protocol

• Increase the dose by 40–80 mg daily every 1–2 weeks based on tremor response and tolerability 1
• Most patients achieve tremor control at 120–320 mg daily in divided doses (immediate-release given 2–3 times daily) 1
• For long-acting formulations, titrate to 120–160 mg once daily as the typical maintenance range 1
• The maximum dose is 640 mg daily if lower doses prove insufficient and the patient tolerates escalation without adverse effects 1

Critical Pre-Treatment Screening

Before initiating propranolol, screen for absolute contraindications that would preclude its use:

• Second- or third-degree atrioventricular block (without a pacemaker) 1, 4
• Decompensated heart failure or significant left ventricular dysfunction 1, 4
• Asthma or obstructive airway disease (propranolol can precipitate life-threatening bronchospasm) 1, 4
• Cardiogenic shock 1
• Sinus node dysfunction or sinus bradycardia (without a pacemaker) 1
• Severe hypotension 1

Obtain baseline heart rate and blood pressure before the first dose 1

Monitoring During Titration

• Monitor heart rate and blood pressure at each dose increase, particularly during the first 1–2 hours after administration 1, 2
• Hold the dose if heart rate falls below 50–60 bpm or systolic blood pressure drops below 90 mmHg 1, 4
• Watch for signs of excessive beta-blockade: marked fatigue, dizziness, light-headedness, new or worsening shortness of breath, or wheezing 1
• In patients with diabetes or a history of hypoglycemia, propranolol masks adrenergic warning signs of low blood glucose (tremor, tachycardia, sweating); instruct these patients to monitor glucose more frequently and rely on non-adrenergic cues such as hunger or confusion 1, 4

Dosing Frequency Considerations

• Immediate-release propranolol should be dosed 2–4 times daily to maintain steady beta-blockade throughout the day 1, 2
• For tremor control, twice-daily dosing is often sufficient (e.g., 80 mg twice daily for a total of 160 mg/day) 1
• Extended-release formulations allow once-daily dosing, which may improve adherence but are less commonly used for tremor 2, 3

Common Pitfalls and Safety Warnings

• Never abruptly discontinue propranolol after chronic use; taper gradually over 1–3 weeks to prevent rebound hypertension, tachycardia, or angina 1, 4
• Avoid routine combination with non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) because this markedly increases the risk of severe bradycardia and heart block 1, 4
• Administer propranolol with food to reduce the risk of hypoglycemia, especially in patients with diabetes or those who have not eaten recently 1
• In patients with severe liver disease (serum albumin <30 g/L), start with a lower dose (20 mg three times daily or 80 mg long-acting daily) and monitor heart rate closely, as propranolol clearance is significantly reduced 5

Dose-Response Considerations

• A biphasic dose-response curve may occur: some patients experience optimal tremor control at moderate doses (120–240 mg/day) but paradoxically worsen if the dose is pushed higher 6
• If tremor control plateaus or worsens despite dose escalation, consider reducing the dose to the last effective level rather than continuing to increase 6
• Only about one-third of patients respond to doses ≤160 mg/day; an additional 40% require 200–640 mg/day for adequate tremor suppression 6

Alternative Beta-Blockers if Propranolol Is Unsuitable

If propranolol is contraindicated or poorly tolerated:

• Metoprolol tartrate (cardioselective): 25 mg twice daily, titrate to a maximum of 200 mg twice daily 1
• Metoprolol succinate (extended-release): 50 mg once daily, titrate to a maximum of 400 mg once daily 1
• Atenolol: 25–50 mg once daily, maximum 100 mg once daily (requires dose reduction in severe renal impairment) 1

Note: Cardioselective beta-blockers (metoprolol, atenolol) may be used with extreme caution in patients with a history of bronchospasm, but all beta-blockers retain some risk of precipitating bronchospasm 1