Can the dose of propranolol (beta blocker) be increased in a patient taking 10mg 6 times a day for anxiety and tremor?

Increasing Propranolol Dosage for Anxiety and Tremor

Yes, the dose of propranolol can be safely increased from the current regimen of 10mg 6 times daily (60mg total) for anxiety and tremor, as this is below the typical therapeutic range for these conditions. 1, 2

Current Dosing and Therapeutic Range

• The current dose of 10mg 6 times daily (60mg total) is below the typical effective range for treating tremor and anxiety 2
• For essential tremor, studies show effective dosing ranges between 120-320mg daily, with maximum tremor suppression typically occurring between 160-320mg daily 2
• For anxiety-related tremor, propranolol doses of 120mg daily have shown significant improvement 3, 4

Recommended Dosing Adjustment

• Increase gradually to minimize potential side effects 2
• A reasonable target would be 20-40mg 3-4 times daily (total daily dose of 80-160mg) 1, 2
• Maximum dose can be increased up to 320mg daily if needed for tremor control, though doses above this threshold rarely provide additional benefit 2

Monitoring During Dose Increases

• Monitor heart rate and blood pressure with each significant dose increase 1
• Watch for potential side effects including:
  • Bradycardia (heart rate below normal range) 1
  • Hypotension 1
  • Fatigue or sleep disturbances 1
  • Bronchospasm in susceptible individuals 1

Important Considerations

• Avoid abrupt discontinuation; if stopping treatment is necessary, taper gradually 1
• Propranolol is contraindicated in patients with:
  • Decompensated heart failure 1
  • Bradycardia or heart block 1
  • Asthma or reactive airway disease 1
  • Uncontrolled hypoglycemia 1

Evidence of Effectiveness

• In studies of essential tremor, all patients showed improvement with propranolol at 120mg daily with no significant side effects 3
• Long-term therapy studies show maintained effectiveness for up to 4 years in some patients 5
• Response tends to be better in younger patients and those with shorter duration of tremor 5
• Some patients (approximately 30%) may not respond adequately to propranolol 6

Potential Limitations

• Tolerance to propranolol may develop in approximately 12.5% of patients with long-term use 6
• Chronic side effects occur in about 17% of patients on long-term propranolol therapy 6
• If tremor control is inadequate with propranolol alone, consider adding or switching to primidone as an alternative 6

Remember that the dose should be adjusted based on clinical response and tolerability, with the goal of finding the lowest effective dose that adequately controls symptoms.