What is the maximum daily dose of atenolol in a typical adult with normal renal function?

Maximum Daily Dose of Atenolol

The maximum daily dose of atenolol is 100 mg once daily for hypertension and angina pectoris in adults with normal renal function. 1, 2

Guideline-Recommended Dosing by Indication

Hypertension

• Initial dose: 25–50 mg once daily 1, 2
• Standard maintenance: 50–100 mg once daily 1, 2
• Maximum dose: 100 mg once daily 1, 2
• Important caveat: Increasing the dose beyond 100 mg daily is unlikely to produce any further antihypertensive benefit 2

Angina Pectoris

• Initial dose: 50 mg once daily 2
• Standard maintenance: 100 mg once daily 2
• Maximum dose: 200 mg once daily for optimal effect in some patients requiring 24-hour control 2
• Key distinction: While 200 mg daily may be used for angina, doses of 50–100 mg provide maximal early effect on exercise tolerance; the 200 mg dose is needed primarily to maintain effect at 24 hours (averaging 50–75% of peak effect) 2

Supraventricular Tachycardia (Ongoing Oral Therapy)

• Initial dose: 25–50 mg once daily 1
• Maximum dose: 100 mg once daily 1
• Dose adjustment required: Reduced dosing in patients with severe renal dysfunction 1

Critical Dosing Principle for Normal Renal Function

For patients with normal renal function, the FDA-approved maximum is 100 mg daily for hypertension, with 200 mg daily reserved only for angina patients requiring extended 24-hour control. 2 The 2017 ACC/AHA hypertension guidelines list atenolol 25–100 mg twice daily as the dosing range, but this reflects divided dosing rather than a higher total daily dose 1. The once-daily formulation at 100 mg is preferred and equally effective 2, 3, 4.

Renal Impairment Dosing Adjustments

Atenolol is predominantly eliminated by the kidneys (95% renal excretion), requiring mandatory dose reduction in renal dysfunction. 2, 5

• Creatinine clearance >35 mL/min: No dose adjustment needed 2
• Creatinine clearance <35 mL/min: Significant accumulation occurs; dose reduction required 2
• Severe renal impairment (GFR <10 mL/min): Elimination half-life increases from 6–9 hours to 36 hours 5
• Elderly patients: Dose selection should start at the low end of the dosing range due to age-related decline in renal function 2

Contraindications That Preclude Any Dose

Before prescribing atenolol at any dose, verify absence of:

• AV block greater than first degree or SA node dysfunction without a pacemaker 1
• Decompensated systolic heart failure 1
• Severe renal dysfunction (requires dose reduction, not contraindication, but mandates adjustment) 1, 2
• Reactive airway disease (relative contraindication; cardioselectivity is dose-dependent and lost at higher doses) 1
• Hypotension 1

Evidence Supporting Once-Daily Dosing at Maximum Dose

Clinical trials demonstrate that atenolol 100 mg once daily provides equivalent blood pressure control to divided dosing and maintains 24-hour efficacy. 3, 4 A double-blind crossover trial in 21 hypertensive patients showed no significant difference in blood pressure reduction between 50 mg, 100 mg, and 200 mg once-daily doses, with all doses reducing BP by approximately 23/16 mmHg (lying) and 22/18 mmHg (standing) 3. For angina, once-daily dosing at 100–200 mg maintains antianginal efficacy throughout the 24-hour period, though maximal exercise tolerance improvement may require 3 months of therapy despite stable serum concentrations 6, 4, 7.

Common Pitfall: Exceeding 100 mg Daily for Hypertension

Do not increase atenolol beyond 100 mg daily for hypertension, as higher doses provide no additional blood pressure benefit and only increase adverse effects. 2 The FDA label explicitly states that "increasing the dosage beyond 100 mg a day is unlikely to produce any further benefit" for hypertension 2. If blood pressure remains uncontrolled at 100 mg daily, add a second antihypertensive agent (thiazide diuretic, calcium channel blocker, or ACE inhibitor) rather than escalating atenolol 2.

Pharmacokinetic Rationale

Atenolol has an elimination half-life of 6–9 hours in patients with normal renal function, supporting once-daily dosing 5, 7. Only 3% is protein-bound, and approximately 50% oral bioavailability is achieved due to incomplete intestinal absorption 5. The linear relationship between plasma levels and beta-blocking effect (measured by exercise-induced tachycardia inhibition) supports the dose-response relationship up to 100 mg, beyond which additional benefit plateaus for most indications 5, 7.