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 30-60 minutes before anxiety-provoking situations, or 40-80 mg daily in divided doses for ongoing anxiety management.

Dosing Regimens

Situational/Performance Anxiety

• Starting dose: 10-40 mg taken 30-60 minutes before anxiety-provoking events
• Frequency: As needed for specific situations (public speaking, performances, exams)
• Evidence: Studies show significant reduction in performance anxiety with 20-40 mg single doses 1, 2
• Clinical pearl: 20 mg provides significant anxiolysis with fewer side effects than 40 mg 2

Generalized Anxiety

• Starting dose: 10-20 mg, 2-3 times daily
• Maintenance dose: 40-80 mg daily in divided doses
• Maximum dose: Up to 160-320 mg daily may be required in severe cases 3
• Duration: Efficacy for periods longer than 4 weeks requires further evaluation 1

Mechanism of Action

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

• Tachycardia
• Tremor
• Palpitations
• Sweating

This peripheral action breaks the anxiety feedback loop where physical symptoms intensify psychological distress 4.

Patient Selection

Propranolol is most effective for:

• Anxiety with prominent somatic/autonomic symptoms 1, 4
• Performance anxiety and social phobias 1
• Moderate anxiety seen in general practice 1
• Recent-onset anxiety not meeting criteria for chronic anxiety disorders 1

Monitoring Parameters

• Heart rate (target: above 50 beats/minute)
• Blood pressure (avoid if systolic BP <90 mmHg)
• Respiratory status (contraindicated in asthma/reactive airway disease)
• Response to therapy (reduction in physical symptoms of anxiety)

Precautions and Contraindications

Propranolol should be avoided or used with extreme caution in patients with:

• Asthma or reactive airway disease 5
• Significant bradycardia (heart rate <50 beats/min) 5
• Heart block greater than first degree 5
• Hypotension (systolic BP <90 mmHg) 5
• Decompensated heart failure 5
• Cardiogenic shock 5

Clinical Pearls

• Propranolol can improve cognitive function in test-anxious students, with one study showing SAT scores improved by 130 points with 40 mg propranolol taken before testing 6
• Beta-blockers are particularly useful for anxiety disorders where benzodiazepines might be avoided due to dependence risks 4
• Lower doses (20-40 mg) are often sufficient for anxiety management, unlike the higher doses used for cardiovascular indications 1, 2
• Effects are typically noticed within 1-2 hours of administration 4

Comparison with Other Treatments

• Unlike benzodiazepines, propranolol does not cause sedation, cognitive impairment, or dependence 1
• More effective for physical symptoms of anxiety than psychological symptoms
• May be used as an adjunct to other anxiety treatments 4
• Consider as an alternative when benzodiazepines are contraindicated or inappropriate

Remember that propranolol primarily addresses the physical manifestations of anxiety. If psychological symptoms predominate, other treatments may be more appropriate.