What is the appropriate dosage of propranolol (beta-blocker) for managing anxiety and tachycardia?

Propranolol Dosing for Anxiety and Tachycardia

For anxiety with tachycardia, propranolol 20mg three times daily is an appropriate starting dose, with titration based on symptom response and heart rate control.

Dosing Guidelines for Propranolol in Anxiety and Tachycardia

Initial Dosing

• Start with propranolol 20mg three times daily (60mg total daily dose)
• This dosage is within the therapeutic range for both anxiety symptoms and tachycardia control
• For acute tachycardia episodes, propranolol can be administered at 1mg IV over 1 minute, repeated up to a total dose of 0.1mg/kg if required 1

Dose Titration

• If initial response is inadequate after 1-2 weeks:
  • Increase to 40mg three times daily (120mg total daily dose)
  • Maximum daily dose for anxiety typically ranges from 80-160mg 2, 3
  • For persistent tachycardia, doses up to 320mg daily may be needed 4

Mechanism of Action

• Propranolol blocks peripheral beta-adrenergic receptors, reducing:
  • Heart rate (chronotropic effect)
  • Tremor
  • Other somatic manifestations of anxiety
• Improvement in anxiety symptoms typically begins within 1-2 hours of administration 2

Clinical Considerations

Monitoring Parameters

• Heart rate (target: reduction of tachycardia to normal range)
• Blood pressure (watch for hypotension)
• Anxiety symptoms (particularly somatic manifestations)
• Signs of bradycardia or heart failure exacerbation

Effectiveness

• Particularly effective for anxiety with prominent somatic symptoms like tremor and palpitations 2, 5
• More effective for performance anxiety and situational anxiety than for severe panic attacks 2
• Can be used as adjunctive therapy with other anti-anxiety medications when somatic symptoms predominate 2

Contraindications and Precautions

• Avoid in patients with:
  • AV block greater than first degree or SA node dysfunction
  • Decompensated heart failure
  • Cardiogenic shock
  • Severe bradycardia
  • Reactive airway disease/asthma
  • Hypotension 1

Important Clinical Pearls

• Beta-blockers like propranolol are particularly effective when somatic symptoms of anxiety (tremor, palpitations) are prominent 2, 5
• Propranolol works primarily through peripheral mechanisms rather than central effects 5
• Do not abruptly discontinue propranolol as this may lead to rebound tachycardia or worsening of anxiety symptoms 6
• If switching from immediate-release to extended-release formulations, dosing is not a simple mg-for-mg substitution and retitration may be necessary 4
• For patients with both anxiety and tachycardia, propranolol offers the advantage of treating both conditions simultaneously 7

While recent systematic reviews suggest limited evidence for beta-blockers in anxiety disorders 8, clinical experience and older studies support their use particularly when physiologic symptoms like tachycardia are present 2, 3.