What is the typical dose of propranolol (beta-blocker) for anxiety?

Propranolol Dosing for Anxiety

For anxiety, propranolol is typically prescribed at 10-40 mg taken 1-3 times daily as needed, with a total daily dose usually not exceeding 120 mg.

Dosing Guidelines

Initial Dosing

• Starting dose: 10-20 mg taken 30-60 minutes before anxiety-provoking situations
• Maintenance dose: 10-40 mg taken 1-3 times daily as needed
• Maximum daily dose: Generally 120 mg for anxiety management

Dosing by Anxiety Type

1. Performance/Situational Anxiety:

   • 10-40 mg taken 30-60 minutes before the anxiety-provoking event
   • Single dose is usually sufficient
   • Can be repeated if necessary for longer events

2. Chronic/Generalized Anxiety:

   • 10-40 mg taken 2-3 times daily
   • Dosing should be spaced evenly throughout the day
   • Total daily dose typically ranges from 40-120 mg

Administration Considerations

• Propranolol can be taken with or without food
• For immediate relief of anxiety symptoms, use immediate-release formulation
• Extended-release formulations are not typically used for as-needed anxiety management
• Effects typically begin within 30-60 minutes of oral administration

Monitoring and Adjustments

• Heart rate: Should be monitored, especially at initiation
• Blood pressure: Should be checked periodically
• Dose adjustment: Based on symptom control and side effects
• Duration: Efficacy for anxiety management beyond 4 weeks has not been well established 1

Precautions and Contraindications

• Contraindicated in: Asthma, COPD, decompensated heart failure, heart block, and bradycardia 2
• Use with caution in: Diabetes, thyroid disorders, and peripheral vascular disease
• Avoid abrupt discontinuation: May cause rebound hypertension or tachycardia

Mechanism for Anxiety Relief

Propranolol primarily works by blocking peripheral adrenergic beta-receptors, reducing somatic symptoms of anxiety such as:

• Tremor
• Palpitations
• Tachycardia
• Sweating

These physical manifestations often contribute to the psychological experience of anxiety, and their reduction can significantly improve overall anxiety symptoms 3.

Evidence for Efficacy

Research demonstrates that propranolol is most effective for anxiety disorders characterized by:

• Prominent somatic symptoms related to increased adrenergic tone
• Moderate intensity anxiety
• Recent onset anxiety
• Performance anxiety such as public speaking or social phobias 1

Studies have shown that propranolol at doses of 40-80 mg daily can effectively control both somatic and psychic symptoms of anxiety, with many patients experiencing lasting remissions and decreased medication requirements over time 4.

Common Pitfalls to Avoid

1. Overlooking contraindications: Always screen for asthma, heart block, or bradycardia before prescribing
2. Abrupt discontinuation: Always taper gradually to avoid rebound symptoms
3. Overtreatment: Higher doses don't necessarily provide better anxiety control but may increase side effects
4. Inadequate monitoring: Regular assessment of heart rate and blood pressure is essential
5. Missing depression: Approximately 50% of anxiety patients may have comorbid depression that may require additional treatment 4

Propranolol is a valuable alternative to benzodiazepines for anxiety management, particularly when somatic symptoms predominate and when concerns about dependence or psychomotor impairment exist.