Propranolol Dosing for Panic Attacks
For panic attacks, propranolol should be dosed at 20-40 mg taken 1-2 hours before anticipated anxiety-provoking situations, with 20 mg being the preferred starting dose due to similar efficacy with fewer side effects. 1
Dosing Guidelines
Initial Dosing
- Start with 20 mg oral propranolol taken 1-2 hours before anticipated anxiety-provoking situations 1
- For ongoing treatment of panic disorder, consider:
- Starting dose: 10-20 mg per dose
- Frequency: As needed for acute symptoms or scheduled for prevention
- Maximum daily dose: Generally not exceeding 40-80 mg/day for anxiety symptoms
Dose Titration
- If 20 mg is insufficient after several trials, may increase to 40 mg 1
- Higher doses (e.g., propranolol 160 mg/day) may be considered for longer-term treatment of anxiety, though evidence is limited 2
- Adjust based on clinical response and side effects
Administration Considerations
- Take with or after food to reduce risk of hypoglycemia 3
- Hold doses during times of diminished oral intake or vomiting 3
- Effects typically begin within 1-2 hours of administration 2
- For acute panic symptoms, can be used as needed rather than scheduled
Clinical Evidence and Efficacy
Propranolol works primarily by blocking peripheral beta-adrenergic receptors, making it most effective for somatic anxiety symptoms:
- Most effective for physical symptoms like tremor and palpitations 2
- Less effective for psychological components of panic disorder 4
- May provide symptomatic relief when combined with other medications (e.g., benzodiazepines) 4, 5
- More effective for milder anxiety symptoms than severe panic attacks 2
Monitoring and Safety
Parameters to Monitor
- Heart rate (watch for bradycardia)
- Blood pressure (watch for hypotension)
- Mood changes (rare cases of mania have been reported) 6
Common Side Effects
- Bradycardia (more common with 40 mg dose - 25% incidence) 1
- Hypotension (more common with 40 mg dose - 10% incidence) 1
- Fatigue
- Sleep disturbances
Important Caveats
- Propranolol is not considered first-line therapy for panic disorder but may be helpful as adjunctive treatment 4, 5
- Most effective when somatic symptoms (particularly cardiovascular) are prominent 4, 2
- Use cautiously in patients with depression as beta-blockers may worsen depressive symptoms 4
- The 20 mg dose appears to provide significant anxiety reduction with minimal side effects compared to 40 mg 1
- Consider combination therapy with benzodiazepines for enhanced efficacy in panic disorder 5
Special Populations
- Use with caution in patients with:
- Asthma or COPD (contraindicated)
- Diabetes (may mask hypoglycemic symptoms)
- Heart block or bradycardia
- Depression (may worsen symptoms)
While the evidence for propranolol in panic disorder is not as robust as for other anxiety treatments, it remains a useful option particularly for patients with prominent physical symptoms or those who cannot tolerate first-line treatments.