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

Propranolol Dosage for Anxiety

For anxiety management, propranolol is typically dosed at 10-40 mg taken 1-3 times daily as needed, with a maximum daily dose of 120-160 mg. 1

Dosing Algorithm for Anxiety

Initial Dosing

• Starting dose: 10-20 mg taken 30-60 minutes before anxiety-provoking situations or events
• Maintenance dose: 20-40 mg 1-3 times daily for ongoing anxiety symptoms
• Maximum daily dose: 120-160 mg (higher doses rarely provide additional benefit) 2

Dosing Based on Anxiety Type

1. Performance/Situational Anxiety:

   • 20-40 mg taken 1 hour before the anxiety-provoking event 3
   • Can be used as needed without daily dosing
   • Shown to significantly improve performance in students with test anxiety 3

2. Chronic Anxiety:

   • 40-80 mg daily divided into 2-3 doses 4
   • May require 2-4 weeks at higher doses (up to 160 mg daily) for optimal effect in chronic anxiety disorders 1

Administration Guidelines

• Take with food to reduce gastrointestinal side effects
• For situational anxiety, administer 1 hour before the anxiety-provoking event
• Hold doses during times of diminished oral intake or vomiting 5
• Avoid abrupt discontinuation after prolonged use; taper gradually

Monitoring Parameters

• Heart rate (target reduction: 10-20% from baseline)
• Blood pressure (monitor for hypotension)
• Symptom improvement (particularly somatic symptoms like tremor, palpitations)

Important Considerations

Mechanism of Action

• Propranolol primarily works by blocking peripheral beta-adrenergic receptors, reducing physical symptoms of anxiety such as tremor, tachycardia, and palpitations 1
• Most effective for anxiety with prominent somatic/autonomic symptoms 6

Efficacy

• Most effective for anxiety characterized by somatic symptoms related to increased adrenergic tone 6
• Particularly effective for performance anxiety and social phobias 6, 3
• Response typically occurs within 1-2 hours of administration 1

Limitations and Cautions

• Less effective for severe panic attacks or anxiety without somatic symptoms
• Contraindicated in asthma, bradycardia, heart block, and uncontrolled heart failure
• May mask symptoms of hypoglycemia in diabetic patients
• Monitor for depression, which can occur in predisposed patients 6

Duration of Treatment

• For situational anxiety: use as needed
• For chronic anxiety: efficacy beyond 4 weeks has not been well established 6
• Consider periodic reassessment of continued need

Comparison to Other Anxiety Treatments

• Unlike benzodiazepines, propranolol does not cause sedation, cognitive impairment, or dependence 6
• Particularly useful when benzodiazepines are contraindicated or concerns about dependence exist 1
• May be used as an adjunct to other anxiety treatments 1