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

Propranolol Dosing for Anxiety

For anxiety, propranolol is typically dosed at 20-40 mg, taken 1-3 times daily as needed, with a total daily dose ranging from 20-120 mg depending on symptom severity and individual response.

Dosing Guidelines

Standard Dosing

• Initial dose: 20-40 mg taken 1-2 hours before anxiety-provoking situations or as needed
• Maintenance dose: 20-40 mg taken 1-3 times daily
• Maximum daily dose: Generally 120-160 mg for anxiety management

Dosing by Anxiety Type

1. Performance/Situational Anxiety:

   • 20-40 mg taken 1-2 hours before the anxiety-provoking event 1
   • Single dose is often sufficient for isolated events

2. Generalized Anxiety with Somatic Symptoms:

   • 20-40 mg, 2-3 times daily (40-120 mg total daily dose) 2
   • Most effective when somatic symptoms (tremor, palpitations) are prominent

3. Severe Anxiety:

   • May require up to 80-320 mg daily in divided doses 3
   • Higher doses should be used cautiously and only when lower doses are ineffective

Administration Considerations

• Immediate-release tablets: Provide effects within 1-2 hours and last 4-6 hours
• Extended-release formulations: Not typically used for as-needed anxiety management
• Timing: For situational anxiety, take 1-2 hours before the anxiety-provoking event

Efficacy Expectations

• Most effective for anxiety with prominent physical symptoms (tremor, palpitations, tachycardia)
• Works primarily by blocking peripheral beta-adrenergic receptors, reducing physical manifestations of anxiety 2
• Effects are typically noticed within 1-2 hours of administration
• More effective for moderate anxiety than severe panic attacks 1

Monitoring and Adjustments

• Assess response by monitoring heart rate (target is reduction of orthostatic and hyperventilatory tachycardia) 3
• Dosage can often be reduced over time as symptoms improve
• Many patients achieve lasting remissions with intermittent use 3

Precautions and Contraindications

• Avoid in patients with:

  • Asthma or obstructive airway disease
  • Decompensated heart failure
  • Significant bradycardia or heart block
  • Hypotension

• Use with caution in patients with:

  • Depression (may potentially worsen symptoms in predisposed individuals)
  • Diabetes (may mask hypoglycemic symptoms)

Common Side Effects

• Fatigue
• Dizziness
• Insomnia
• Nausea
• Bradycardia and hypotension (more common with higher doses) 4

Clinical Pearls

• Lower doses (20 mg) often provide significant anxiolysis with minimal side effects 4
• Propranolol primarily addresses the physical symptoms of anxiety, which can help break the anxiety cycle
• Unlike benzodiazepines, propranolol does not cause sedation, cognitive impairment, or dependence
• Effects contrast sharply with those of traditional tranquilizers 3