What are the recommended adult doses, contraindications, adverse effects, and monitoring parameters for propranolol?

Propranolol: Adult Dosing, Contraindications, Adverse Effects, and Monitoring

Recommended Adult Doses

Propranolol dosing varies significantly by indication, with immediate-release formulations requiring 2-4 times daily administration and extended-release allowing once-daily dosing. 1

Hypertension

• Immediate-release: 80-160 mg daily in 2 divided doses 1
• Extended-release: Start 80 mg once daily, usual maintenance 120-160 mg once daily, maximum 640 mg daily 2
• Target blood pressure reduction: at least 20/10 mmHg, ideally to <140/90 mmHg 1

Angina Pectoris

• Extended-release: Start 80 mg once daily, gradually increase at 3-7 day intervals until optimal response 2
• Average optimal dose: 160 mg once daily 2
• Maximum studied dose: 320 mg daily 2
• Note: Gradual discontinuation over several weeks is mandatory to prevent rebound angina 2

Situational/Performance Anxiety

• Single-dose use: 10-20 mg taken 30-60 minutes before the anxiety-provoking event, maximum single dose 40 mg 1
• Chronic daily use (for frequent episodes): 40 mg twice daily (immediate-release), titrate to 80-160 mg daily in divided doses 1
• Alternative: Extended-release 80 mg once daily, titrate to 120-160 mg once daily 1

Migraine Prophylaxis

• Extended-release: Start 80 mg once daily, usual effective range 160-240 mg once daily 2
• If no response after 4-6 weeks at maximum dose, discontinue therapy 2

Atrial Fibrillation Rate Control

• Immediate-release: 10-40 mg 3-4 times daily 1
• IV (acute): 1 mg over 1 minute, may repeat every 2 minutes as needed, maximum 3 doses 1

Supraventricular Tachycardia

• Oral maintenance: 30-60 mg daily in divided doses or single dose with long-acting formulation, maintenance 40-160 mg daily 1

Absolute Contraindications

Propranolol must never be initiated in patients with the following conditions: 2

1. Cardiogenic shock 2
2. Second- or third-degree atrioventricular block (without a functioning pacemaker) 1, 2
3. Sinus bradycardia or sinus node dysfunction (without a pacemaker) 1
4. Bronchial asthma or obstructive airway disease (risk of life-threatening bronchospasm) 1, 2
5. Decompensated heart failure or severe left ventricular dysfunction 1
6. Severe hypotension (systolic BP <90 mmHg) 1
7. Known hypersensitivity to propranolol 2

Additional Relative Contraindications

• History of bronchospasm 1
• Diabetes with history of hypoglycemic episodes (propranolol masks hypoglycemia symptoms) 1
• Concurrent use of non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe bradycardia/heart block risk 1

Mandatory Pre-Treatment Assessment

Before initiating propranolol, the following baseline evaluation is required: 1

• Cardiovascular examination: Heart rate, blood pressure measurement, cardiac auscultation 1
• Screen for contraindications: History of heart block, asthma, heart failure, hypotension 1
• Assess for bronchospasm history and reactive airway disease 1
• Diabetes screening: History of hypoglycemic episodes 1
• Medication review: Identify drugs affecting cardiac conduction (digoxin, calcium channel blockers, amiodarone) 1
• ECG and echocardiogram: Only needed in selected cases with cardiac concerns, not routine in otherwise healthy adults 1

Common Adverse Effects

The most frequently encountered side effects include: 1

• Cardiovascular: Bradycardia, hypotension, dizziness, cold extremities 1
• Metabolic: Masking of hypoglycemia symptoms (tremor, tachycardia, sweating) in diabetic patients 1
• Respiratory: Bronchospasm (especially in patients with underlying reactive airway disease) 1
• Cardiac: Potential worsening of heart failure 1
• General: Fatigue, lightheadedness 1

Serious Adverse Effects Requiring Immediate Attention

• Severe bradycardia (heart rate <50 bpm with symptoms) 1
• Symptomatic hypotension (systolic BP <90 mmHg with dizziness, confusion) 1
• New or worsening dyspnea/wheezing 1
• Signs of worsening heart failure (edema, weight gain, dyspnea) 1

Monitoring Parameters

Baseline Monitoring

• Heart rate and blood pressure 1
• No routine laboratory work (CBC, renal, liver, thyroid function) required in otherwise healthy adults 1

Ongoing Monitoring

• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
• Monitor for hypotension and bradycardia, especially during dose escalation 1
• Diabetic patients: More frequent blood glucose monitoring required, as propranolol masks adrenergic warning signs of hypoglycemia 1

Signs Requiring Dose Adjustment or Discontinuation

• Heart rate <50 bpm with symptoms 1
• Systolic blood pressure <90 mmHg with symptoms 1
• New wheezing requiring treatment 1
• Significantly reduced oral intake or vomiting 1

Critical Safety Warnings

Abrupt Discontinuation

Never abruptly discontinue propranolol after chronic use—this can precipitate rebound hypertension, tachycardia, or angina. 1 Taper gradually over 1-3 weeks when discontinuing 1.

Drug Interactions

• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to markedly increased risk of bradycardia and heart block 1
• Contraindicated with dofetilide 1
• CYP3A4 inhibitors (diltiazem, verapamil) can elevate propranolol concentrations 1

Special Populations

• Elderly patients: May require lower doses due to altered pharmacokinetics 1
• Diabetic patients: Use with extreme caution; propranolol masks hypoglycemia symptoms and requires more frequent glucose monitoring 1
• Pregnant women: Considered safe first-line agent but associated with intrauterine growth retardation; use lowest effective dose 3

Administration Considerations

• Take with food to reduce risk of hypoglycemia 1
• Hold doses during times of diminished oral intake or vomiting 1
• Scored tablets can be safely split in half along the score line for dose adjustment 4
• Extended-release formulations: Not a simple mg-for-mg substitute for immediate-release; retitration may be necessary 2

Common Pitfalls to Avoid

• Do not use propranolol as first-line monotherapy for uncomplicated hypertension—current guidelines prioritize ACE inhibitors/ARBs, calcium channel blockers, and thiazide diuretics 1
• Do not assume all beta-blockers are interchangeable—atenolol is less effective for blood pressure control and lacks proven benefit for situational anxiety 1
• Do not initiate in decompensated heart failure—wait until clinical stabilization 1
• Do not combine with non-dihydropyridine calcium channel blockers without careful consideration of bradycardia/heart block risk 1