Propranolol Dosing Guidelines

Standard Adult Dosing by Indication

For hypertension, initiate propranolol immediate-release at 80 mg daily divided into 2 doses (40 mg twice daily), or propranolol extended-release at 80 mg once daily, titrating to a maintenance range of 80–160 mg daily; the maximum dose is 640 mg daily if needed. 1, 2

Hypertension

Start with 80 mg daily in 2 divided doses (immediate-release) or 80 mg once daily (extended-release) 1, 2
Titrate to 120–160 mg daily for maintenance 1, 2
Maximum dose: 640 mg daily 1

Angina Pectoris

Average optimal dose: 500–800 mg daily for moderate to severe angina 3
Mean effective dose in long-term studies: 255 mg daily 4
Dose-dependent efficacy demonstrated up to 417 mg daily 3

Cardiac Arrhythmias

Atrial fibrillation rate control: 10–40 mg immediate-release, 3–4 times daily 1
Supraventricular tachycardia (oral maintenance): 30–60 mg daily, titrating to 40–160 mg daily 1
IV for acute settings: 1 mg over 1 minute, may repeat every 2 minutes up to 3 doses 1

Migraine Prophylaxis

Typical range: 80–240 mg daily in divided doses 2
Start low and titrate based on response 2

Essential Tremor

Therapeutic range: 80–240 mg daily 2
Maximum dose: 240 mg daily if needed for adequate tremor control 2

Situational/Performance Anxiety

For infrequent, predictable anxiety-provoking situations: 10–20 mg taken 30–60 minutes before the event; maximum single dose 40 mg 1
For chronic daily anxiety with prominent somatic symptoms: 40 mg twice daily (80 mg total), titrating to 80–160 mg daily in 2 divided doses 1
Extended-release alternative: 80 mg once daily, titrating to 120–160 mg once daily 1

Pediatric Dosing

For infantile hemangiomas, start propranolol at 1 mg/kg/day divided into 2–3 doses with food, increase after 24 hours to a maintenance dose of 2 mg/kg/day, and use a maximum of 3 mg/kg/day for non-responders. 5, 6

Standard Pediatric Algorithm (Uncomplicated Cases)

Starting dose: 1 mg/kg/day divided into 2–3 doses 5, 6
Maintenance dose: 2 mg/kg/day (standard for uncomplicated cases) 5, 6
Maximum dose: 3 mg/kg/day for inadequate response 5, 6
Minimum interval between dose increases: 24 hours 5

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

Suspected PHACES syndrome (segmental facial hemangiomas) 5, 6
Preterm infants or <48 weeks postconceptional age 5, 6
Infants <8 weeks of age 5, 6
Low birth weight or faltering growth 5, 6
Comorbidities increasing hypoglycemia risk (hyperinsulinism, history of hypoglycemia) 5, 6
Poor feeding or metabolic/neurological disorders 5

Pediatric Administration Guidelines

Always administer with or after feeding to reduce hypoglycemia risk 5, 6
Hold doses during diminished oral intake, vomiting, or acute illness 5, 6
Maintain dosing intervals ≤8 hours (≤6 hours in younger infants) 5, 6
Use 5 mg/5 mL preparation to minimize dosing errors 5

Duration of Pediatric Treatment

Continue until at least 12 months of age (ideally 12–15 months) to minimize rebound growth 6
Greatest rebound risk occurs when discontinued before 9 months 6
Most patients do not require treatment beyond 17 months 5, 6
Safe to stop abruptly (no taper required) in infantile hemangioma treatment 5

Pediatric Cardiac Indications

Historical pediatric cardiac dosing: 0.5–4.0 mg/kg/day for dysrhythmias, IHSS, and hypoxemic spells 7

Elderly Patients

Elderly patients require lower starting doses due to altered pharmacokinetics; initiate at 40 mg twice daily (immediate-release) or 80 mg once daily (extended-release) and titrate more gradually. 1, 2

Start at half the standard adult dose 1, 2
Titrate more slowly than in younger adults 2
Monitor closely for hypotension and bradycardia 1

Hepatic Impairment

Propranolol requires dose adjustment in hepatic impairment due to reduced first-pass metabolism and increased bioavailability. 8

Dose reduction necessary due to decreased hepatic clearance 8
Start at lower doses and titrate cautiously 8
Monitor for signs of excessive beta-blockade 1

Renal Impairment

Propranolol does not require renal dose adjustment, as it is primarily hepatically metabolized; however, consider cardioselective alternatives (metoprolol, atenolol with renal dosing) if beta-blockade is needed in severe renal dysfunction. 1, 8

No routine renal dose adjustment required 8
Age, gender, race, and ethnicity do not alter pharmacokinetics 8

Formulation Differences

Immediate-Release

Half-life: 3–6 hours 1
Dosing frequency: 2–4 times daily for most indications 1
Twice daily acceptable for hypertension 1

Extended-Release (Long-Acting)

Half-life: 8–20 hours 1, 9
Dosing frequency: Once daily 1, 9
Bioavailability 30–50% less than immediate-release due to increased hepatic metabolism 9
Peak concentrations lower and delayed compared to immediate-release 9
Maintains constant plasma levels and beta-blockade throughout 24 hours 9

Mandatory Pre-Treatment Assessment

Before initiating propranolol, perform cardiovascular and respiratory examination with auscultation, measure baseline heart rate and blood pressure, and screen for absolute contraindications including second- or third-degree heart block, decompensated heart failure, asthma, cardiogenic shock, and sinus node dysfunction. 5, 1, 2

Standard Assessment (All Patients)

Cardiovascular examination with auscultation 5, 2
Baseline heart rate and blood pressure 1, 2
Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 1

Selective Additional Testing

ECG indicated only if: abnormal heart rate for age, strong family history of sudden death or arrhythmia, episodes of loss of consciousness, maternal history of connective tissue disease, or suspected cardiac abnormalities 5, 2
Echocardiogram indicated only if: segmental head/neck hemangiomas (suspected PHACES), abnormal cardiac examination, or known cardiac disease 5, 2
Baseline glucose: only in patients at risk of hypoglycemia (preterm, low weight, faltering growth, neonates, history of hypoglycemia) 5
Routine blood work (CBC, renal, liver, thyroid) NOT required in otherwise healthy patients 5, 1

Pediatric PHACES Syndrome

Brain MRI/MRA ideally before full-dose propranolol 5
ECG and echocardiogram interpreted by pediatric cardiologist mandatory 5
Discuss with pediatric neurologist if arterial stenosis or agenesis present 5

Post-Initiation Monitoring

Standard Patients (Low Risk)

No routine monitoring required if patient remains stable and asymptomatic 1, 2
Heart rate and blood pressure do not need monitoring between appointments 5, 1
Follow-up only if symptoms of excessive beta-blockade develop 1

High-Risk Pediatric Patients

Measure heart rate and blood pressure immediately before first dose 5, 6
Monitor every 30 minutes for 2–4 hours after first dose 5, 6
High-risk includes: age <4 weeks, preterm, faltering growth, feeding difficulties, significant comorbidities 5

Routine Pediatric Follow-Up

Stable patients on maintenance dose: every 2–3 months 5
Dose can be adjusted for weight at clinic visits, by GP, or by parents with written instructions 5

Absolute Contraindications

Propranolol is absolutely contraindicated in second- or third-degree heart block, decompensated heart failure, asthma or obstructive airway disease, cardiogenic shock, sinus node dysfunction without pacemaker, severe hypotension, and recent or ongoing hypoglycemic episodes. 5, 1, 2, 6

Second- or third-degree atrioventricular block (without pacemaker) 5, 1, 2, 6
Decompensated heart failure or severe left ventricular dysfunction 1, 2, 6
Asthma or obstructive airway disease (risk of life-threatening bronchospasm) 5, 1, 2, 6
Cardiogenic shock 1, 2, 6
Sinus node dysfunction or sinus bradycardia (without pacemaker) 1, 2, 6
Severe hypotension (systolic BP <90 mm Hg) 1
Recent or ongoing hypoglycemic episodes 5, 6
Known hypersensitivity to propranolol 5, 6

Critical Drug Interactions

Avoid routine combination of propranolol with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to markedly increased risk of severe bradycardia and heart block. 1

Non-dihydropyridine calcium channel blockers (diltiazem, verapamil): increased risk of bradycardia and heart block 1
Dofetilide: contraindicated combination 1
CYP3A4 inhibitors (diltiazem, verapamil): further elevate propranolol concentrations 1
Digoxin, amiodarone, ivabradine: additive bradycardic effects, use with caution 1

Discontinuation Guidelines

Never abruptly discontinue propranolol after chronic use; taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina. 1, 2

Chronic Use (Cardiovascular Indications)

Always taper gradually over 1–3 weeks 1, 2
Abrupt discontinuation can precipitate rebound hypertension, tachycardia, or angina 1, 2

Infantile Hemangiomas

Safe to stop abruptly without taper 5
Exception to the cardiovascular discontinuation rule 5

Temporary Holding During Acute Illness

May hold temporarily without taper during reduced oral intake, vomiting, or wheezing requiring treatment 1
Re-start at lower dose and up-titrate once oral intake normalizes 1

Signs of Excessive Beta-Blockade

Monitor for dizziness, marked fatigue, heart rate <50 bpm, systolic blood pressure <90 mm Hg, and new or worsening shortness of breath or wheezing as signs of excessive beta-blockade. 1

Dizziness or light-headedness 1
Marked fatigue 1
Heart rate <50 beats/min 1
Systolic blood pressure <90 mm Hg 1
New or worsening shortness of breath/wheezing 1
Cold extremities 1

Special Safety Considerations

Hypoglycemia Risk

Propranolol masks adrenergic warning signs of hypoglycemia (tremor, rapid heartbeat, sweating) 1
Patients with diabetes or history of hypoglycemia should monitor blood glucose more frequently 1
Rely on non-adrenergic cues (hunger, confusion, sweating) to detect hypoglycemia 1
Always administer with food in pediatric patients 5, 2, 6

Bronchospasm Risk

Non-selective β-blockade (β1 and β2) causes bronchoconstriction 1
Even mild wheezing or COPD warrants cardioselective alternative (metoprolol, atenolol) 1
Cardioselective agents still carry dose-related bronchospasm risk 1

Vascular Effects

β2-receptor blockade causes vasoconstriction, leading to cold extremities 1
May exacerbate peripheral vascular disease 1

Cardioselective Alternatives When Propranolol Is Unsuitable

Alternative Agent	Typical Adult Dose	Key Considerations
Metoprolol tartrate	25–50 mg twice daily; max 200 mg twice daily	β₁-selective; no renal adjustment; less effective for tremor/anxiety [1]
Metoprolol succinate (ER)	50 mg once daily; max 400 mg once daily	β₁-selective; once-daily dosing [1]
Atenolol	25–50 mg once daily; max 100 mg once daily	β₁-selective; requires renal dose adjustment [1]
Nadolol	40 mg once daily; max 320 mg once daily	Non-selective; requires renal dose adjustment [1]

All beta-blockers remain contraindicated in active asthma 1
Cardioselective agents preferred in borderline pulmonary function or mild reactive airway disease 1

Clinical Pearls

Dose-dependent bioavailability: A 2-fold increase in dose results in a 2.5-fold increase in AUC 8
Propranolol is substrate of CYP2D6, CYP1A2, and CYP2C19 8
For situational anxiety, propranolol is NOT suitable for chronic daily anxiety; SSRIs/SNRIs are first-line for generalized anxiety 1
Propranolol is most effective for performance anxiety with prominent somatic symptoms (tremor, palpitations, sweating) 1
Atenolol is NOT recommended as an alternative antihypertensive due to inferior blood pressure control 1

What are the typical oral dosing regimens of propranolol for adults (including essential hypertension, angina pectoris, cardiac arrhythmias, migraine prophylaxis, and essential tremor) and how should the dose be adjusted for elderly patients, those with hepatic impairment, and children?

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