What is the recommended dosing for propranolol (beta blocker) for anxiety?

Propranolol Dosing for Anxiety

For anxiety management, propranolol should be dosed at 20-40 mg, one to three times daily (total of 20-120 mg/day), with dosing adjusted based on symptom severity and individual response. 1

Dosing Guidelines

Initial Dosing

• Start with 20-40 mg per dose
• Can be administered 1-3 times daily depending on symptom pattern
• Take with or after food to reduce risk of hypoglycemia 2

Maintenance Dosing

• Typical effective range: 40-120 mg total daily dose
• For somatic anxiety symptoms (physical manifestations like tremor, palpitations): Lower doses often effective (40-80 mg/day) 3, 4
• For more severe or persistent anxiety: May require up to 160 mg/day 4
• Maximum reported effective dose in severe cases: Up to 320 mg/day, though such high doses are rarely needed 5

Clinical Considerations

Patient Selection

• Most effective for anxiety with prominent somatic symptoms:
  • Tremor
  • Palpitations
  • Tachycardia
  • Sweating
  • Performance anxiety
• Less effective for purely psychological anxiety symptoms 3

Monitoring

• Assess heart rate response to determine adequate beta-blockade
• Target is significant reduction in orthostatic and hyperventilatory tachycardia 5
• Monitor blood pressure, especially during dose adjustments

Duration of Treatment

• Short-term use (days to weeks) is appropriate for situational anxiety
• Clinical efficacy beyond 4 weeks requires further evaluation 1
• Some patients may benefit from intermittent use for specific anxiety-provoking situations 5

Precautions and Contraindications

• Hold doses during periods of reduced oral intake or vomiting 2
• Use with caution in patients with:
  • Bradycardia
  • Hypotension
  • Asthma or reactive airway disease
  • Diabetes (can mask hypoglycemia symptoms)
  • Heart failure

Common Pitfalls to Avoid

1. Overuse or self-medication: There is potential for inappropriate self-medication with propranolol for anxiety, which should be monitored 6

2. Overlooking depression: Depression may coexist with anxiety and may require separate treatment 5

3. Expecting complete symptom resolution: Propranolol typically moderates rather than completely eliminates anxiety symptoms

4. Using for all anxiety types: Propranolol is most effective for somatic anxiety symptoms and performance anxiety, not generalized psychological anxiety 3, 4

5. Inadequate dosing: Failure to adjust dose to achieve adequate beta-blockade may result in suboptimal response

Remember that propranolol works quickly (within 1-2 hours) for somatic anxiety symptoms, making it particularly useful for situational anxiety like performance anxiety or public speaking 4.