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

Propranolol Starting Dose for Anxiety

For anxiety in adults, start propranolol at 20-40 mg daily, administered once to three times per day, with or after food. 1, 2

Pre-Treatment Assessment Requirements

Before initiating propranolol, perform the following mandatory evaluations:

• Cardiovascular examination including heart rate, blood pressure measurement, and cardiac auscultation 1
• Screen for absolute contraindications: second or third-degree heart block, decompensated heart failure, asthma or reactive airway disease, hypotension, cardiogenic shock, sinus node dysfunction without pacemaker, and recent hypoglycemic episodes 1
• Medication review for drugs affecting cardiac conduction 1
• History screening for bronchospasm and diabetes 1

Dosing Strategy

Initial Dosing

• Start with 20-40 mg daily in divided doses (once to three times daily) 1, 2
• The 20 mg dose provides significant anxiety reduction with minimal side effects 3
• Administer with food to reduce hypoglycemia risk 1

Dose Titration

• Adjust dosage to achieve optimal clinical response and significant beta-blockade (evidenced by virtual abolition of orthostatic and hyperventilatory tachycardia) 4
• Typical therapeutic range: 80-320 mg daily for sustained anxiety control 4
• Some patients may temporarily require up to 1200 mg daily for unusually intense symptoms 4
• Maximum maintenance dose: 40-160 mg daily in divided doses or as single dose with long-acting formulations 1

Duration Considerations

• Clinical efficacy beyond 4 weeks of continuous treatment remains incompletely demonstrated 2
• Long-term use (several days to over 10 years) has been documented, with many patients experiencing diminishing propranolol requirements over time 4

Patient Selection

Propranolol is most effective for:

• Patients with predominantly somatic anxiety symptoms (tremor, palpitations, tachycardia, sweating, autonomic symptoms) rather than purely psychic anxiety 1, 5
• Anxiety of moderate intensity, especially in general practice settings 2
• Recent-onset anxiety not meeting DSM criteria for specific chronic anxiety disorders 2
• Performance anxiety (public speaking, social phobias) when episodes are limited in number 2

Monitoring During Treatment

• Monitor for hypotension and bradycardia, particularly during dose escalation 1
• Hold doses during diminished oral intake or vomiting 1
• Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities 1
• Bradycardia occurred in 25% and hypotension in 10% of patients receiving 40 mg doses 3

Critical Safety Considerations

• Never abruptly discontinue after chronic use; taper gradually to prevent rebound hypertension, tachycardia, or angina 1
• Propranolol may mask hypoglycemia symptoms in susceptible patients 1
• Lower doses may be required for patients with comorbidities or experiencing adverse effects 1
• Depression may persist in approximately one-third of patients as a lone symptom requiring antidepressant therapy 4

Comparative Context

The evidence strongly supports propranolol over benzodiazepines as first-line treatment when somatic anxiety symptoms predominate, avoiding the psychomotor impairment and dependence risks associated with benzodiazepines 2. Propranolol was more effective than placebo specifically in patients with somatic anxiety, but not in those with primarily psychic anxiety 5.