Is propranolol (beta blocker) effective for treating panic attacks?

Propranolol for Panic Attacks

Propranolol is not recommended as a treatment for panic attacks due to insufficient evidence of effectiveness and negative findings in controlled studies. 1

Evidence on Propranolol for Panic Attacks

Guideline Recommendations

• Current clinical guidelines do not support propranolol as a treatment for panic disorder 1
• Propranolol has been specifically deprecated for social anxiety disorder based on negative evidence 1
• First-line treatments for anxiety disorders remain SSRIs, SNRIs, and cognitive behavioral therapy 1

Research Evidence

Multiple controlled studies have evaluated propranolol for panic disorder with consistent findings:

• A double-blind study comparing propranolol to placebo and alprazolam found propranolol was not effective for panic disorder and agoraphobia with panic attacks, while alprazolam showed efficacy 2
• Another controlled trial comparing diazepam and propranolol in 21 patients with panic disorder and agoraphobia found diazepam significantly superior on all measures, with propranolol failing to reduce panic attacks or phobic symptoms 3
• Early research investigating propranolol for PTSD prevention showed no statistically significant difference between propranolol and placebo in preventing PTSD at 1 month (18% vs 30%) or 3 months (11% vs 13%) 4

Limited Potential Applications

While propranolol is not effective for panic attacks specifically, it may have limited utility in:

• Performance anxiety with somatic symptoms (10-40mg taken 1-2 hours before performance) 1
• Managing physical symptoms like tremor and palpitations in anxious individuals 1
• As an adjunctive treatment for residual somatic complaints when combined with established treatments 5

One small study from 1991 suggested potential efficacy 6, but this finding has not been replicated in larger, more rigorous trials and contradicts the majority of evidence.

Important Considerations and Contraindications

If considering propranolol for anxiety-related somatic symptoms (not panic attacks):

• Contraindicated in patients with:

  • Asthma or COPD
  • Heart block greater than first-degree
  • Cardiogenic shock
  • Heart failure 1

• Potential side effects include:

  • Bradycardia and hypotension
  • Sleep disturbances
  • Respiratory effects
  • Discoloration with cooling of extremities 1

• Caution: Propranolol may potentially induce depression in predisposed patients, making it particularly problematic for panic disorder patients who often have comorbid depression 5

Clinical Bottom Line

For patients with panic attacks, evidence-based treatments include:

1. SSRIs/SNRIs as first-line pharmacotherapy
2. Cognitive behavioral therapy
3. Benzodiazepines (like alprazolam) for acute management

Propranolol should not be used as a primary treatment for panic attacks based on current evidence, though it might help manage peripheral somatic symptoms in specific cases where standard treatments have failed.