Propranolol for Anxiety: Evidence-Based Recommendations
Propranolol is not recommended as a first-line treatment for generalized anxiety disorder due to insufficient evidence of effectiveness, but may be beneficial specifically for performance anxiety with somatic symptoms like tremor and palpitations. 1
Efficacy by Anxiety Type
Performance Anxiety/Social Phobia
- Propranolol is most effective for performance anxiety (stage fright) where physical symptoms predominate
- Works primarily by blocking peripheral beta-adrenergic receptors, preventing physical manifestations of anxiety without causing sedation 1
- Typical dosage: 10-40mg taken 1-2 hours before performance 1
- Most beneficial for mild tremor rather than severe symptoms 1, 2
Generalized Anxiety Disorder
- Not recommended as first-line treatment 1
- SSRIs, SNRIs, and cognitive behavioral therapy remain evidence-based first-line treatments 1
- Limited evidence for effectiveness in chronic anxiety conditions 3
Panic Disorder
- Not supported by evidence for routine use 3
- May provide symptomatic relief for residual somatic complaints when combined with other medications 3
Dosing Considerations
- For performance anxiety: 10-40mg 1-2 hours before event 1
- For anxiety with somatic symptoms: 20-40mg, 1-3 times daily 1
- Women may require lower doses (50-100% lower) due to higher bioavailability 1
- Effects typically last 4-6 hours 1
- Some older studies used much higher doses (up to 320mg daily), but this is not standard practice 4
Important Contraindications
- Asthma or COPD
- Heart block greater than first-degree
- Cardiogenic shock
- Heart failure 1
Common Side Effects
- Bradycardia and hypotension (usually mild)
- Sleep disturbances (reported in 2-18.5% of patients)
- Respiratory effects (labored breathing, wheezing)
- Discoloration with cooling of extremities 1
- Potential to induce depression in predisposed patients 1, 3
Clinical Pearls
- Most effective when somatic symptoms of anxiety are prominent but not extreme 2
- More valuable for mild tremor (as in musicians) than severe shaking during panic attacks 2
- Benefits are typically noticed within 1-2 hours of administration 2
- May be useful as an adjunct to other anxiety treatments 2
- Should be used cautiously, if at all, in patients with concurrent depression 3
Limitations of Evidence
- Many studies on propranolol for anxiety have design problems 5
- Long-term efficacy beyond 4 weeks is not well established 6
- Evidence is stronger for specific situational anxiety than for chronic anxiety disorders 1
While some older research suggested broader applications for propranolol in anxiety 4, more recent guidelines and evidence do not support its use as a primary treatment for generalized anxiety disorder or panic disorder. Its utility is primarily in managing the physical symptoms of performance anxiety.