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

Propranolol Dosing for Anxiety

For anxiety, propranolol is typically dosed at 10-40 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

Situational/Performance Anxiety

• Starting dose: 10-20 mg taken 30-60 minutes before anxiety-provoking situations
• Frequency: As needed for specific events (public speaking, performances, exams)
• Evidence: Effective for performance anxiety at relatively low doses (20-40 mg) with improvement noted within 1-2 hours 1

Generalized Anxiety

• Starting dose: 10-20 mg
• Frequency: 2-3 times daily
• Maintenance range: 40-120 mg daily in divided doses
• Maximum daily dose: Generally not exceeding 160 mg for anxiety management

Dosing Algorithm

1. Initial approach: Start with 10-20 mg for mild anxiety symptoms
2. Titration: Increase by 10-20 mg every 3-7 days based on response
3. Target: Lowest effective dose that controls physical symptoms of anxiety
4. Duration: Efficacy for periods longer than 4 weeks remains to be conclusively demonstrated 2

Clinical Efficacy

• Most effective for anxiety with prominent somatic symptoms (tremor, palpitations, sweating) related to increased adrenergic tone 2

• Particularly beneficial for:

  • Performance anxiety and social phobias 2
  • Moderate anxiety seen in general practice 2
  • Recent-onset anxiety 2

• A study of patients with test anxiety showed significant improvement with a single 40 mg dose taken one hour before testing 3

• Another study found both 20 mg and 40 mg doses effective for perioperative anxiety, with 20 mg providing significant anxiety reduction with fewer side effects 4

Important Considerations

Monitoring

• Assess heart rate and blood pressure before initiating therapy
• Target should be virtual abolition of orthostatic and hyperventilatory tachycardia 5
• Monitor for bradycardia and hypotension, especially with higher doses

Contraindications

• Asthma or obstructive airway disease
• Decompensated heart failure
• Greater than first-degree AV block or significant sinus node dysfunction
• Cardiogenic shock
• Severe bradycardia 6

Side Effects

• Common: Fatigue, dizziness, nausea, insomnia
• Cardiovascular: Bradycardia, hypotension (10% with 40 mg dose) 4
• Respiratory: Bronchospasm in susceptible individuals
• Potential cognitive effects and risk of depression in predisposed patients 2

Clinical Pearls

• Propranolol requirements typically diminish over time 5
• Extended-release formulations are not a simple mg-for-mg substitute for immediate-release tablets 7
• Unlike benzodiazepines, propranolol does not carry risk of dependence or psychomotor impairment 2
• Consider starting with 20 mg dose for anxiety as it provides significant reduction in anxiety with minimal side effects 4