Propranolol Extended-Release Dosing
For adults with hypertension, angina, or migraine, initiate propranolol ER at 80 mg once daily and titrate to a maintenance dose of 120-160 mg once daily, with a maximum of 640 mg daily for hypertension. 1
Standard Adult Dosing by Indication
Hypertension
- Initial dose: 80 mg once daily (alone or with diuretic) 1
- Maintenance dose: 120-160 mg once daily 1
- Maximum dose: 640 mg daily may be required in some cases 1
- Titration: Increase gradually until adequate blood pressure control is achieved; full response may take days to several weeks 1
Angina Pectoris
- Initial dose: 80 mg once daily 1
- Titration: Increase gradually at 3-7 day intervals until optimal response 1
- Maintenance dose: Average optimal dose is 160 mg once daily 1
- Maximum dose: Safety and efficacy beyond 320 mg daily not established 1
- Discontinuation: Reduce gradually over several weeks to avoid rebound angina 1
Migraine Prophylaxis
- Initial dose: 80 mg once daily 1
- Effective range: 160-240 mg once daily 1
- Trial duration: If no satisfactory response within 4-6 weeks at maximum dose, discontinue 1
- Discontinuation: Withdraw gradually over several weeks depending on patient age, comorbidities, and dose 1
Hypertrophic Subaortic Stenosis
- Usual dosage: 80-160 mg once daily 1
Important Dosing Considerations
Conversion from Immediate-Release
Propranolol ER is NOT a simple mg-for-mg substitute for immediate-release propranolol. 1 The extended-release formulation has different pharmacokinetics and produces lower blood levels, requiring retitration to maintain effectiveness, especially at the end of the 24-hour dosing interval 1.
Pharmacokinetic Profile
- Extended-release formulation maintains plasma concentrations at 24 hours better than conventional tablets 2
- Terminal half-life: 8-11 hours (longer than immediate-release) 3
- Bioavailability: 30-50% less than conventional formulation due to increased hepatic metabolism 3
- Peak concentrations are lower and delayed compared to immediate-release 3
Critical Safety Points
Drug Interactions Requiring Dose Adjustment
- Cimetidine: Increases propranolol AUC by 46% and Cmax by 35% 1
- Nisoldipine: Increases propranolol Cmax by 50% and AUC by 30% 1
- Nicardipine: Increases propranolol Cmax by 80% and AUC by 47% 1
- Cholestyramine/colestipol: Decreases propranolol concentrations up to 50% 1
Gradual Discontinuation Required
Always taper propranolol ER gradually over several weeks when discontinuing, particularly in patients with angina, to prevent rebound symptoms and potential cardiovascular events 1.
Note: The evidence provided primarily addresses pediatric dosing for infantile hemangiomas (2-3 mg/kg/day) 4, 5, which is a distinct indication from standard adult extended-release dosing for cardiovascular and neurological conditions.