What is the therapeutic dose of propranolol (beta blocker) for anxiety?

Therapeutic Dosing of Propranolol for Anxiety

The therapeutic dose of propranolol for anxiety typically ranges from 20-40 mg, taken 1-3 times daily, with a total daily dose of 40-120 mg being effective for most patients with anxiety. 1

Dosing Guidelines

• Initial dosing of propranolol for anxiety typically ranges from 30-60 mg daily, which can be divided into multiple doses or given as a single dose with long-acting formulations 2
• For anxiety treatment, particularly those characterized by somatic symptoms related to increased adrenergic tone, doses of 20-40 mg taken 1-3 times daily are generally effective 1
• The maximum maintenance dose of propranolol is typically 40-160 mg daily in divided doses or as a single dose with long-acting formulations 2
• Clinical efficacy of beta-blockers for anxiety has primarily been demonstrated for treatment periods of up to 4 weeks 1

Clinical Applications

• Propranolol is most effective for anxiety disorders that are:
  • Characterized by prominent somatic symptoms related to increased adrenergic tone (e.g., palpitations, tremor) 1
  • Of moderate intensity and/or commonly seen in general practice 1
  • Of recent onset rather than chronic anxiety disorders meeting DSM criteria 1
• Propranolol is particularly useful for performance anxiety such as public speaking or specific social phobias 1
• Beta-blockers are more effective for relatively mild symptoms (e.g., tremor in musicians during performance) than for severe symptoms experienced during panic attacks 3

Monitoring and Contraindications

• Baseline assessment of heart rate and blood pressure is recommended before initiating propranolol treatment 2
• Monitoring for potential adverse effects including hypotension, bradycardia, bronchospasm, and worsening heart failure is advised 2
• Propranolol is contraindicated in patients with:
  • Asthma or obstructive airway disease 2
  • Decompensated heart failure 2
  • Second or third-degree heart block 2
  • History of hypoglycemic episodes 2

Important Clinical Considerations

• Propranolol may mask symptoms of hypoglycemia in susceptible patients 2
• Abrupt discontinuation should be avoided to prevent rebound hypertension or tachycardia 2
• Higher doses (up to 160-320 mg daily) may be required in some cases of severe anxiety, though this is less common 4
• Beta-blockers should be used cautiously in patients with concurrent depressive illness as they may potentially induce or worsen depression 5
• Some patients may require long-term treatment, though requirements typically diminish over time 4

Comparative Efficacy

• Propranolol may be considered as an alternative to benzodiazepines, particularly when:
  • Somatic symptoms predominate 1
  • Concerns exist about psychomotor impairment or dependence with benzodiazepines 1
  • Previous treatment with benzodiazepines has proven ineffective or caused adverse effects 4
• Beta-blockers may be useful as adjuncts to existing anxiety treatments, especially when physical symptoms persist 3