Friend prescribed propranolol 40mg bid neuroleptic-induced akathisia. safe to start there right away or should this dose built on titration schedule?

Should be safe : This should be a safe dose if your friend is not asthmatic, diabetic, or has any cardiovascular history.

Depends on BP.: This is a modest dose. I usually start low at 10 mg. Tid depending on the blood pressure and titrate up depending on the response.

Try lower dose first: I usually give 20 mg test dose looking for any side effects or dizziness, then go with 20 mg bid for a week to test effects on akathisia, tremor, pulse and bp. Dose adjustments are either 20 mg tid or 10 mg bid. I rarely need to have patient increase to 40 mg bid. As long as benefit > side effects then ok to increase.