Propranolol in the Management of Anxiety
Propranolol is not recommended as a first-line treatment for generalized anxiety disorder due to insufficient evidence of effectiveness, with recent guidelines specifically deprecating its use based on negative evidence. 1
Mechanism of Action
Propranolol is a nonselective beta-adrenergic receptor blocking agent that:
- Blocks peripheral beta-adrenergic receptors, preventing catecholamines from binding
- Reduces physical manifestations of anxiety such as heart rate, blood pressure, and tremor
- Does not affect cognitive function or cause sedation 2, 3
Evidence for Use in Different Anxiety Conditions
Generalized Anxiety Disorder
- Not supported by current evidence for routine use
- The Canadian Clinical Practice Guidelines specifically deprecate propranolol for social anxiety disorder based on negative evidence 1
- A 2025 systematic review and meta-analysis found no evidence for beneficial effects compared to either placebo or benzodiazepines 4
Performance Anxiety
- May be beneficial for performance anxiety with somatic symptoms
- Typical dosage: 10-40mg taken 1-2 hours before performance 2
- Most effective for physical symptoms like tremor and palpitations 5
- Works rapidly (within 1-2 hours) at relatively low doses 5
Social Phobia
- Limited evidence for effectiveness in specific social phobias when limited in number 6
- More effective for mild tremor (e.g., anxious musician) than severe symptoms 5
Dosing Considerations
- For performance anxiety: 10-40mg taken 1-2 hours before event 2
- For anxiety with somatic symptoms: 20-40mg, 1-3 times daily 6
- Women may require lower doses due to higher oral bioavailability and slower clearance 2
- Effects typically last 4-6 hours 2
Contraindications
- Asthma or COPD
- Heart block greater than first-degree
- Cardiogenic shock
- Heart failure 2
Side Effects
- Bradycardia and hypotension (usually mild and asymptomatic)
- Sleep disturbances (reported in 2-18.5% of patients)
- Respiratory effects (labored breathing, wheezing)
- Discoloration with cooling of hands and feet 1, 2
- May potentially induce depression in predisposed patients 6, 7
Clinical Considerations
When to Consider Propranolol
- For performance anxiety with prominent somatic symptoms
- As adjunctive therapy for anxiety with cardiovascular symptoms
- For patients who cannot tolerate or have contraindications to first-line treatments
When to Avoid Propranolol
- In patients with asthma or COPD
- In patients with cardiac conduction abnormalities
- In patients with depression or at risk for depression
- As monotherapy for generalized anxiety disorder
Alternative Beta-Blockers
- Some evidence suggests atenolol may be better tolerated than propranolol for anxiety symptoms
- In one military study, 100% of patients who had previously taken propranolol reported preferring atenolol 8
Conclusion
Propranolol has a limited role in anxiety management, primarily for performance anxiety with prominent physical symptoms. For generalized anxiety disorder, SSRIs, SNRIs, and cognitive behavioral therapy remain the evidence-based first-line treatments, with propranolol specifically not recommended based on current guidelines.