How to transition from prazosin (alpha blocker) to propranolol (beta blocker) for panic attacks?

Transitioning from Prazosin to Propranolol for Panic Attacks

Direct Answer

Do not transition from prazosin to propranolol for panic attacks, as propranolol has not demonstrated efficacy for panic disorder and may worsen outcomes. 1, 2, 3

Evidence Against Propranolol for Panic Disorder

Propranolol is not effective for treating panic disorder itself. Multiple controlled trials have consistently shown that propranolol fails to reduce panic attacks or phobic avoidance compared to placebo or active comparators 4, 5, 6. The evidence is clear:

• In a controlled crossover study, diazepam was significantly superior to propranolol on all measures, with panic attacks and phobic symptoms responding to diazepam but not propranolol 5
• A 5-week double-blind study found alprazolam effective but propranolol no better than placebo for panic disorder 6
• Propranolol may only provide symptomatic relief for residual somatic complaints like palpitations and tachycardia when combined with other medications, not as monotherapy 4

Limited Role of Propranolol in Anxiety

Propranolol is indicated for performance anxiety and specific situational anxiety, not generalized panic disorder. 1, 2, 3

• The American Heart Association notes propranolol is commonly prescribed for panic disorder symptom relief but should be combined with cognitive behavioral therapy and/or SSRIs/benzodiazepines 1
• Canadian Clinical Practice Guidelines do not recommend beta-blockers as first-line treatment for social anxiety disorder due to negative evidence 3
• Propranolol works by blocking peripheral effects of adrenaline (tremor, rapid heart rate, nervousness) but does not address the core panic disorder pathology 2

Critical Safety Concern

Combining prazosin (alpha-blocker) with propranolol (beta-blocker) can cause significant hypotension. 7

• The FDA label for prazosin explicitly warns: "Hypotension may develop in patients given prazosin hydrochloride who are also receiving a beta-blocker such as propranolol" 7
• This means any transition must involve complete discontinuation of prazosin before starting propranolol, not a gradual crossover

Recommended Approach

Instead of transitioning to propranolol, consider evidence-based treatments for panic disorder:

• First-line pharmacological options: SSRIs or SNRIs 3
• First-line non-pharmacological: Cognitive behavioral therapy 1, 3
• If benzodiazepines are needed: Alprazolam has demonstrated efficacy for panic disorder 8, 9, 6

If Propranolol Must Be Used

If propranolol is being considered for prominent cardiovascular symptoms only (not as primary panic treatment):

• Completely discontinue prazosin first to avoid hypotensive interaction 7
• Start propranolol at low doses (the FDA label notes initial dosing considerations) 10
• Combine with proven anti-panic medications (SSRIs or benzodiazepines), as propranolol alone will not control panic attacks 1, 4
• Monitor for depression, as beta-blockers may induce depressive symptoms 4

Key Contraindications to Propranolol

Before any propranolol use, ensure the patient does not have: 1, 2

• Asthma or COPD
• Bradycardia or heart block
• Cardiac failure
• Raynaud disease
• Depression (relative contraindication)