Propranolol Dosing for Anxiety in Adults
For anxiety in adults, propranolol should be dosed at 10-40 mg taken 30-60 minutes before anxiety-provoking situations for performance anxiety, or 20-40 mg two to three times daily (total 80-120 mg/day) for generalized anxiety with prominent somatic symptoms, with doses up to 320 mg/day used in some cases.
Patient Selection
Propranolol is most effective for anxiety characterized by prominent somatic/physical symptoms rather than purely psychological symptoms 1, 2. Target patients include those with:
- Tremor, palpitations, tachycardia, and sweating 1
- Performance anxiety (public speaking, social phobias) 3
- Moderate intensity anxiety, particularly in primary care settings 3
- Recent onset anxiety not meeting criteria for chronic anxiety disorders 3
Propranolol is less effective for purely psychic anxiety (worry, rumination) without somatic manifestations 2.
Mandatory Pre-Treatment Assessment
Before initiating propranolol, perform 1:
- Heart rate and blood pressure measurement
- Cardiovascular examination with auscultation
- Screen for history of bronchospasm, diabetes, and cardiac conduction abnormalities
Absolute Contraindications
Do not use propranolol in patients with 1:
- Second or third-degree heart block
- Decompensated heart failure or significant left ventricular dysfunction
- Asthma or reactive airway disease
- Cardiogenic shock or severe hypotension
- Recent or ongoing hypoglycemic episodes
- Sinus node dysfunction without a pacemaker
Dosing Regimens
For Performance Anxiety (Situational)
- 10-40 mg as a single dose taken 30-60 minutes before the anxiety-provoking event 3
- This is the most common use in clinical practice for public speaking, presentations, or specific social situations 3
For Generalized Anxiety with Somatic Symptoms
Starting dose: 20-40 mg once to three times daily 3, 4
Typical therapeutic range: 80-320 mg daily in divided doses 4, 5
Dose titration: Adjust to achieve clinical response and significant beta-blockade (virtual abolition of orthostatic and hyperventilatory tachycardia) 4
Maximum doses: Some patients required up to 1200 mg daily for intense symptoms in long-term studies, though 80-320 mg sufficed for most 4
Administration Guidelines
- Administer with food to reduce hypoglycemia risk 1
- Hold doses during diminished oral intake or vomiting 1
- Monitor for hypotension and bradycardia, especially during dose escalation 1
Duration of Treatment
- Short-term use (days to weeks) is typical for performance anxiety 3
- Clinical efficacy beyond 4 weeks for chronic anxiety remains incompletely demonstrated 3
- Long-term use (months to years) has been reported in clinical practice with good tolerance 4
Common Pitfalls and Safety Considerations
Abrupt discontinuation: Never stop propranolol suddenly after chronic use, as this can precipitate rebound hypertension, tachycardia, or angina—taper gradually 1
Common adverse effects include 1:
- Fatigue and dizziness (often difficult to distinguish from anxiety symptoms) 6
- Bradycardia and hypotension
- Cold extremities
- Potential worsening of heart failure
Depression concerns: While depression lifted in many anxious patients on propranolol, it may persist or worsen in predisposed individuals 3, 4
Cognitive effects: Potential impairment of cognitive function remains controversial 3
Masking hypoglycemia: Propranolol may mask symptoms of hypoglycemia in diabetic patients 1
Comparative Effectiveness
Research suggests that diazepam is generally more effective than propranolol for overall anxiety relief, but propranolol outperforms placebo specifically in patients with somatic anxiety 2. Propranolol should be considered as an alternative to benzodiazepines, particularly to avoid psychomotor impairment and dependence 3, 5.