Propranolol for Anxiety: Dosage and Treatment Protocol
For anxiety management, propranolol should be dosed at 20-40 mg taken 1-3 times daily as needed, with a maximum of 120 mg per day for most patients. This dosing regimen targets the somatic symptoms of anxiety while minimizing side effects.
Dosing Protocol
Initial Dosing
- Start with 10-20 mg taken 30-60 minutes before anxiety-provoking situations
- For ongoing anxiety management, begin with 20 mg twice daily
- Dose can be taken as needed for situational anxiety (like public speaking)
Dose Titration
- If initial response is inadequate, increase to 40 mg per dose
- Maximum recommended daily dose for anxiety is 120-160 mg divided throughout the day
- Allow at least 24 hours between dose increases to assess response
Administration Guidelines
- Take with or after food to reduce risk of hypoglycemia
- For performance anxiety, take 30-60 minutes before the anxiety-provoking event
- For chronic anxiety, maintain regular dosing schedule
Clinical Considerations
Patient Selection
- Best for anxiety with prominent somatic symptoms (palpitations, tremor, sweating)
- Particularly effective for performance anxiety and social phobias
- Less effective for generalized anxiety disorder without physical symptoms
- Consider as alternative when benzodiazepines are contraindicated or concerns about dependence exist
Monitoring
- Assess heart rate and blood pressure at baseline and during dose adjustments
- Target heart rate should remain above 60 beats per minute
- Monitor for hypoglycemia, especially in patients with diabetes or irregular eating patterns
Duration of Treatment
- For situational anxiety: short-term, as-needed use is appropriate
- For chronic anxiety: efficacy beyond 4 weeks has not been well established 1
- Periodic reassessment of continued need is recommended
Precautions and Contraindications
Contraindications
- Bradycardia (heart rate <60 bpm)
- Hypotension (systolic BP <100 mmHg)
- Heart block greater than first degree
- Cardiogenic shock or acute heart failure
- Severe COPD or asthma
Common Side Effects
- Fatigue and dizziness
- Sleep disturbances
- Cold extremities
- Gastrointestinal disturbances
Important Warnings
- Do not abruptly discontinue after prolonged use (taper over 1-2 weeks)
- May mask symptoms of hypoglycemia in diabetic patients
- Use with caution in patients with depression, as beta-blockers may exacerbate depressive symptoms 2
Clinical Evidence and Recommendations
The Canadian Clinical Practice Guidelines note that beta-blockers like propranolol are not recommended as first-line treatments for social anxiety disorder based on negative evidence 3. However, they remain useful for specific situations:
- Most effective for anxiety with prominent physical symptoms 1, 4
- Particularly valuable for performance anxiety and specific social phobias 1
- Can provide relief within 1-2 hours at relatively low doses 5
- May be used as an adjunct to other anxiety treatments 2, 5
For chronic anxiety requiring medication, propranolol should be considered as an alternative to benzodiazepines when concerns about dependence exist 4, 5. The therapeutic effect is primarily achieved through peripheral beta-blockade of somatic symptoms rather than central anxiolytic effects.