Propranolol Dosing for Anxiety
For anxiety disorders, initiate propranolol at 20-40 mg once to three times daily, with typical effective doses ranging from 40-160 mg daily in divided doses, depending on symptom severity and whether treating chronic generalized anxiety versus acute performance anxiety.
Initial Dosing Strategy
Start with 20-40 mg once to three times daily for generalized anxiety with prominent somatic symptoms 1. The American College of Cardiology recommends initial dosing typically ranges from 30-60 mg daily in divided doses or as a single dose with long-acting formulations 2.
- For acute performance anxiety (public speaking, social phobias): Use 20-40 mg as a single dose 1-2 hours before the anxiety-provoking event 1, 3
- For chronic generalized anxiety: Begin with 40 mg daily and titrate upward based on response 3
- Lower doses (20 mg) are equally effective as 40 mg for perioperative anxiety with fewer side effects (bradycardia 25%, hypotension 10% with 40 mg dose) 4
Dose Titration and Maintenance
Adjust dosage to achieve optimal clinical response and adequate beta-blockade, evidenced by virtual abolition of orthostatic and hyperventilatory tachycardia 5.
- Typical maintenance range: 80-320 mg daily in divided doses for chronic anxiety 5
- The American College of Cardiology states maximum maintenance dose is typically 40-160 mg daily in divided doses or as a single dose with long-acting formulations 2
- Higher doses (up to 160 mg daily) may be needed for several weeks of treatment to see improvement in non-somatic anxiety symptoms 3
- Some patients may temporarily require up to 1200 mg daily for unusually intense symptoms, though this is exceptional 5
Pre-Treatment Assessment
Check for absolute contraindications before initiating propranolol: asthma or obstructive airway disease, decompensated heart failure, second or third-degree heart block, and history of hypoglycemic episodes 2.
- Obtain baseline heart rate and blood pressure 2
- The American College of Cardiology recommends baseline cardiovascular assessment before initiating propranolol 2
- No routine monitoring is required for most patients after initiation 2
Monitoring During Treatment
Monitor for hypotension and bradycardia, especially at higher doses 2.
- Watch for bronchospasm and worsening heart failure 2
- Propranolol may mask hypoglycemia symptoms in susceptible patients 2
- Administer with food to reduce hypoglycemia risk, and hold doses during diminished oral intake or vomiting 2
Clinical Efficacy Considerations
Propranolol works best for anxiety with prominent somatic/autonomic symptoms (tremor, palpitations, sweating) rather than purely psychological symptoms 1, 3.
- Improvement occurs within 1-2 hours for acute dosing 3
- For chronic treatment, clinical efficacy beyond 4 weeks remains to be fully demonstrated 1
- Depression (present in 50% of anxiety patients) usually improves but may persist in one-third as a lone symptom requiring antidepressants 5
Discontinuation
Avoid abrupt discontinuation to prevent rebound hypertension or tachycardia 2.
- Reduce dosage gradually over several weeks, especially in patients on higher doses or with comorbidities 2, 6
Common Pitfalls
- Do not use propranolol for severe panic attacks with extreme shaking—it is more effective for mild-to-moderate somatic symptoms 3
- Lower doses may be required in patients with comorbidities or those experiencing adverse effects 2
- Extended-release formulations are not mg-for-mg substitutes for immediate-release tablets and require retitration 6