What is the typical dosing regimen for propranolol (beta blocker) in the treatment of anxiety?

Propranolol Dosing for Anxiety Treatment

For anxiety treatment, propranolol should be dosed at 20-40 mg, one to three times daily, with a typical duration of treatment not exceeding 4 weeks for optimal efficacy and safety. 1

Patient Selection and Indications

• Propranolol is most effective for anxiety characterized by prominent somatic symptoms related to increased adrenergic tone (e.g., palpitations, tremor, tachycardia) 1, 2
• Best results are seen in anxiety of moderate intensity and/or in primary care settings 1
• Particularly useful for performance anxiety such as public speaking or specific social phobias 1
• More effective for recent-onset anxiety rather than chronic anxiety disorders meeting full DSM criteria 1

Dosing Protocol

• Starting dose: 20-40 mg per dose 1
• Frequency: 1-3 times daily (typically before anxiety-provoking situations for situational anxiety) 1
• Maximum daily dose: 120 mg (though higher doses up to 320 mg daily have been used in some cases) 3
• Duration: Clinical efficacy beyond 4 weeks has not been well demonstrated 1

Combination Therapy Considerations

• May be used in combination with benzodiazepines for enhanced effect in patients with prominent physical symptoms 4, 5
• Can provide symptomatic relief for residual somatic complaints when added to existing anxiety treatment regimens 4
• The combination of propranolol with diazepam has shown greater efficacy than either medication alone in some studies 5

Monitoring Parameters

• Heart rate reduction of >7.5 beats per minute may predict better therapeutic response 5
• Monitor for hypotension and bradycardia, especially at higher doses 6
• No routine blood pressure or heart rate monitoring is required for most patients, but baseline assessment is recommended 6

Contraindications and Cautions

• Avoid in patients with:
  • Asthma or obstructive airway disease 6
  • Decompensated heart failure 6
  • Second or third-degree heart block 6
  • History of hypoglycemic episodes 6
  • Concurrent depression or high risk for depression 4

Clinical Pearls

• Propranolol primarily addresses the physical manifestations of anxiety rather than the psychological components 2
• Patients with predominantly somatic anxiety symptoms respond better than those with primarily psychological symptoms 2
• Propranolol requirements often diminish over time, and lasting remissions can occur 3
• Consider discontinuing if no benefit is observed after 2-4 weeks of adequate dosing 1
• Abrupt discontinuation is generally safe, without need for tapering 3