Propranolol Dosing for Performance Anxiety
For performance anxiety, propranolol should be administered at a dose of 20-40 mg taken 1 hour before the anxiety-provoking event. This dosing regimen provides optimal anxiolytic effects while minimizing potential side effects.
Dosing Guidelines
- Standard dose: 20-40 mg taken 1 hour before performance 1, 2
- Frequency: Single dose as needed before anxiety-provoking events
- Formulation: Immediate-release tablets preferred for situational use
Evidence for Effectiveness
Research demonstrates that propranolol effectively reduces performance anxiety by:
- Blocking peripheral manifestations of anxiety (tremor, tachycardia, sweating) 3
- Improving cognitive function during stressful situations 4
- Reducing observable signs of anxiety in public speaking scenarios 3
A study of surgical residents found that 40 mg of propranolol taken 1 hour before surgery significantly decreased both tremor and anxiety without compromising performance or causing significant side effects 5.
Dosing Considerations
Factors that may require dose adjustment:
Lower starting dose (10-20 mg) for:
- Patients with low body weight
- First-time users
- Elderly patients
- Patients with mild hepatic or renal impairment
Higher dose (40 mg) for:
- Patients with more severe symptoms
- Those who had inadequate response to lower doses
- Larger individuals
Precautions and Contraindications
Propranolol should be avoided in patients with:
- Asthma or obstructive airway disease
- Decompensated heart failure
- Heart block (second and third degree)
- Bradycardia
- Hypotension
Administration Tips
- Take with or after food to reduce the risk of hypoglycemia 6
- Hold doses during times of diminished oral intake or vomiting 6
- For predictable events (presentations, performances), a trial dose is recommended beforehand to assess individual response and tolerance
Monitoring
No special monitoring is required for occasional use in healthy individuals. However, patients should be aware of potential side effects including:
- Bradycardia
- Hypotension
- Fatigue
- Dizziness
- Sleep disturbances
Clinical Pearl
While the American Heart Association guidelines mention propranolol dosing of 0.5-1 mg intravenously for cardiac indications 6, the evidence for performance anxiety supports oral dosing of 20-40 mg as the optimal regimen, with 20 mg providing significant anxiolysis with minimal side effects 2.