Propranolol Dosing for Episodic Anxiety
For episodic anxiety, propranolol should be dosed at 20-40 mg taken 1-3 times daily as needed, with a typical effective dose being 20 mg taken 1-2 hours before an anxiety-provoking event. 1, 2
Dosing Recommendations
- Initial dose: 20 mg taken 1-2 hours before anticipated anxiety-provoking situations
- Dosing frequency: As needed, can be taken 1-3 times daily
- Maximum daily dose: Generally 120 mg for episodic anxiety
- Duration of effect: 4-6 hours per dose
Clinical Considerations
Patient Selection
Propranolol is most effective for anxiety characterized by:
- Prominent somatic symptoms (tremor, palpitations, sweating)
- Performance or situational anxiety (public speaking, social phobias)
- Moderate intensity anxiety 1
- Recent onset anxiety rather than chronic anxiety disorders
Efficacy Considerations
- Most effective for somatic manifestations of anxiety rather than psychological symptoms 3
- Clinical response is typically seen within 1-2 hours of administration 4
- For episodic use, lower doses (20-40 mg) are generally sufficient 2
- Higher doses (up to 160 mg/day) may be needed for more persistent anxiety, but this requires longer treatment periods 4
Administration Guidelines
- Take with or after food to reduce the risk of hypoglycemia 5
- For performance anxiety, take approximately 1-2 hours before the anxiety-provoking event
- Hold doses during times of diminished oral intake or vomiting 5
Monitoring and Safety
- Monitor heart rate and blood pressure during initial dosing
- Be cautious in patients with:
- Bradycardia
- Hypotension
- Asthma or reactive airway disease
- Diabetes (may mask hypoglycemic symptoms)
Common Side Effects
- Bradycardia (more common with 40 mg dose) 2
- Hypotension (more common with 40 mg dose) 2
- Fatigue
- Sleep disturbances
- Dizziness
Clinical Pearl
While 20 mg and 40 mg doses of propranolol are both effective for anxiety, the 20 mg dose typically provides significant reduction in anxiety with minimal side effects, making it the preferred starting dose for most patients with episodic anxiety 2.