What are the recommended adult dosing regimens, contraindications, and monitoring parameters for propranolol?

Propranolol: Adult Dosing, Contraindications, and Monitoring

Propranolol is a non-selective beta-blocker with multiple FDA-approved indications; dosing varies widely by indication (10–640 mg/day), and absolute contraindications include decompensated heart failure, second- or third-degree AV block without a pacemaker, active asthma, cardiogenic shock, and sinus node dysfunction. 1

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Dosing Regimens by Indication

Hypertension

• Immediate-release (IR): Start 80 mg/day divided into 2 doses; titrate to 80–160 mg/day in 2 divided doses. 1
• Long-acting (LA): Start 80 mg once daily; titrate to 120–160 mg once daily. 1
• Maximum dose: 640 mg/day if needed, though typical maintenance is 160 mg/day. 1
• Target blood pressure reduction: ≥20/10 mmHg, ideally to <140/90 mmHg. 1

Situational (Performance) Anxiety

• As-needed dosing: 10–20 mg taken 30–60 minutes before the anxiety-provoking event; maximum single dose 40 mg. 1
• Chronic daily dosing (if frequent episodes): Start 40 mg twice daily (IR); titrate to 80–160 mg/day in 2 divided doses, or use LA 80 mg once daily titrated to 120–160 mg once daily. 1, 2
• Best candidates: Adults with infrequent, predictable situations and prominent somatic symptoms (tremor, palpitations, sweating). 1
• Poor candidates: Chronic daily anxiety or primarily psychological symptoms—use SSRIs/SNRIs instead. 1

Supraventricular Tachycardia (Oral Maintenance)

• Start 30–60 mg/day (divided or single LA dose); maintenance 40–160 mg/day. 1

Atrial Fibrillation Rate Control

• IR: 10–40 mg three to four times daily. 1
• Alternative: 80–160 mg/day divided into 2 doses (twice daily acceptable for hypertension indication). 1

Post-Myocardial Infarction (Secondary Prevention)

• Target dose: 200 mg/day (LA formulation preferred); titrate gradually over 2–3 weeks. 1

Migraine Prophylaxis

• Typical effective range: 80–160 mg/day; target dose often 200 mg/day for optimal prophylaxis. 1, 3

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Absolute Contraindications

Before prescribing propranolol, screen for the following absolute contraindications: 1

• Second- or third-degree AV block (without a functioning pacemaker) 1
• Decompensated heart failure or severe left-ventricular dysfunction 1
• Asthma or obstructive airway disease (risk of life-threatening bronchospasm due to non-selective β2 blockade) 1
• Cardiogenic shock 1
• Sinus node dysfunction or sinus bradycardia (without a pacemaker) 1
• Severe hypotension (systolic BP <90 mmHg) 1
• Recent or ongoing hypoglycemic episodes 1

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Pre-Treatment Assessment

Mandatory Screening

• Cardiovascular examination with auscultation to detect heart failure, murmurs, or arrhythmias. 1
• Baseline heart rate and blood pressure measurement. 1
• Screen for history of bronchospasm, diabetes, and concurrent medications (especially non-dihydropyridine calcium-channel blockers like diltiazem/verapamil, which markedly increase bradycardia and heart block risk). 1

When to Obtain ECG/Echocardiogram

• ECG and echocardiogram are NOT routinely required in otherwise healthy adults. 1
• Obtain ECG/echo only if: suspected cardiac abnormalities, segmental head/neck conditions, or abnormal cardiac examination. 1

Laboratory Work

• Routine blood work (CBC, renal, liver, thyroid function) is NOT required before starting propranolol in otherwise healthy adults. 1

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Administration and Safety Considerations

Dosing Frequency

• Immediate-release half-life: 3–6 hours; requires 2–4 times daily dosing (twice daily acceptable for hypertension). 1
• Extended-release half-life: 8–20 hours; allows once-daily dosing. 1, 4

Food and Hypoglycemia Risk

• Administer propranolol with food to reduce hypoglycemia risk, especially in patients with diabetes or history of hypoglycemia. 1
• Hold doses during diminished oral intake or vomiting. 1
• Propranolol masks adrenergic warning signs of hypoglycemia (tremor, tachycardia, sweating); patients must rely on non-adrenergic cues (hunger, confusion) and monitor glucose more frequently. 1

Discontinuation

• Never abruptly discontinue propranolol after chronic use—taper gradually over 1–3 weeks to prevent rebound hypertension, tachycardia, or angina. 1, 2

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Monitoring Parameters

During Initiation and Titration

• Monitor for hypotension and bradycardia, especially during dose escalation. 1
• Watch for signs of excessive beta-blockade: dizziness, marked fatigue, heart rate <50 bpm, systolic BP <90 mmHg, new or worsening dyspnea/wheezing. 1

Ongoing Monitoring

• In stable patients on low-dose propranolol for anxiety: Routine vital sign monitoring between appointments is not required if the patient is asymptomatic. 1
• For cardiovascular indications: Check heart rate and blood pressure at each visit; target resting heart rate 50–60 bpm unless limiting side effects occur. 1

Special Populations

• Elderly patients: May require lower doses due to altered pharmacokinetics; start at the lowest dose and titrate more gradually. 1, 2
• Women: May achieve optimal outcomes at 50% of guideline-recommended doses due to 50–80% higher drug exposure compared to men. 5

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Major Drug Interactions

• Avoid routine combination with non-dihydropyridine calcium-channel blockers (diltiazem, verapamil)—markedly increases risk of severe bradycardia and heart block. 1
• Contraindicated with dofetilide. 1
• CYP3A4 inhibitors (e.g., diltiazem, verapamil) can further elevate propranolol concentrations. 1

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Common Adverse Effects

• Fatigue, bradycardia, hypotension, dizziness, cold extremities, potential worsening of heart failure. 1, 2
• Bronchospasm in patients with reactive airway disease (even mild COPD). 1

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Alternatives When Propranolol Is Unsuitable

For Cardiovascular Indications

Alternative	Typical Dosing	Notes
Metoprolol tartrate (cardioselective)	25 mg BID; max 200 mg BID	No renal dose adjustment required [1]
Metoprolol succinate (ER)	50 mg daily; max 400 mg daily	Once-daily dosing [1]
Atenolol	25–50 mg daily; max 100 mg daily	Requires renal dose adjustment [1]
Nadolol	40 mg daily; max 320 mg daily	Requires renal dose adjustment [1]

For Anxiety with Contraindications

• Cardioselective beta-blockers (metoprolol, atenolol) may be used with extreme caution in mild reactive airway disease, but all beta-blockers retain some bronchospasm risk. 1
• Non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) may be considered for rate control but are not effective for tremor or anxiety indications. 1

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Key Clinical Pearls

• Propranolol's non-selective β2 blockade causes bronchoconstriction (contraindicated in asthma) and vasoconstriction (cold extremities, may worsen peripheral vascular disease). 1
• For dual indication (hypertension + situational anxiety): Maintain baseline antihypertensive dose (e.g., 80 mg/day divided) and add supplemental 10–20 mg IR 30–60 minutes before known anxiety-provoking events; max single situational dose 40 mg. 1
• Propranolol is NOT first-line for uncomplicated hypertension—contemporary guidelines prioritize ACE-I/ARB, calcium-channel blockers, and thiazide diuretics. 1
• For chronic anxiety disorders: SSRIs/SNRIs are first-line; propranolol is explicitly deprecated for generalized social anxiety disorder. 1

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Evidence Strength

The dosing recommendations and contraindications are supported by strong guideline consensus from the American College of Cardiology, American Heart Association, and Japanese Society of Anxiety and Related Disorders, reflecting Class I evidence for cardiovascular indications that inform off-label anxiety use. 1, 2