Propranolol Dosage for Anxiety
For anxiety management, propranolol should be dosed at 20-40 mg taken 1-3 times daily as needed, with a maximum daily dose of 120-160 mg. This dosing regimen provides effective control of somatic anxiety symptoms while minimizing side effects 1, 2.
Dosing Algorithm
- Initial dosage: 20 mg taken 30-60 minutes before anxiety-provoking situations or 20 mg three times daily for ongoing anxiety
- Titration: If needed, increase to 40 mg per dose
- Maximum daily dose: 120-160 mg divided throughout the day
Mechanism and Effectiveness
Propranolol works primarily by blocking peripheral beta-adrenergic receptors, reducing physical symptoms of anxiety such as:
- Tremor
- Palpitations
- Tachycardia
- Sweating
The medication is most effective when:
- Somatic symptoms are prominent but not extreme 3
- Anxiety is of moderate intensity 1
- Used for performance or situational anxiety 1
Clinical Evidence
Research demonstrates that propranolol at 20-40 mg doses provides significant anxiolysis within 1-2 hours of administration 3, 2. A comparative study showed that propranolol (80-320 mg/day) was superior to placebo and comparable to chlordiazepoxide in reducing anxiety symptoms as measured by standardized anxiety scales 4.
Long-term studies have shown that propranolol in doses of 80-320 mg daily can effectively control both somatic and psychic symptoms of anxiety, with many patients requiring lower doses over time 5.
Important Considerations
- Onset of action: Effects begin within 1-2 hours of administration
- Duration: Effects typically last 4-6 hours per dose
- Side effects: Monitor for bradycardia and hypotension, which occur more frequently at higher doses (40 mg vs 20 mg) 2
- Contraindications:
- Asthma or reactive airway disease
- Bradycardia (heart rate <50 beats/minute)
- Heart block
- Cardiogenic shock
- Uncontrolled heart failure
Advantages Over Benzodiazepines
- No risk of dependence or addiction
- No psychomotor impairment
- No sedation at recommended doses
- Particularly effective for performance anxiety
Clinical Pearls
- Lower doses (20 mg) provide significant anxiolysis with minimal side effects 2
- For situational anxiety (public speaking, performances), take 20-40 mg approximately 30-60 minutes before the event
- For chronic anxiety, divided doses (3 times daily) provide more consistent symptom control
- Propranolol should not be abruptly discontinued after prolonged use
- Patients with diabetes should be monitored as propranolol can mask hypoglycemic symptoms
Propranolol represents an effective alternative to benzodiazepines for anxiety management, particularly when physical symptoms are prominent or when concerns about dependence exist.