Propranolol Dosing for Performance Anxiety
For performance anxiety, propranolol should be dosed at 10-40 mg taken as a single dose 30-60 minutes before the anxiety-provoking event, with 40 mg being the most commonly studied and effective dose. 1
Pre-Treatment Mandatory Assessment
Before prescribing propranolol for performance anxiety, you must exclude absolute contraindications 1:
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or reactive airway disease
- Hypotension
- Cardiogenic shock
- Recent or ongoing hypoglycemic episodes
- Sinus node dysfunction without a pacemaker 2
Perform a baseline cardiovascular assessment including 1:
- Heart rate and blood pressure measurement
- Cardiovascular examination with auscultation
- History screening for bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
Routine blood work, ECG, or echocardiogram are NOT required in otherwise healthy adults without cardiac concerns. 1
Specific Dosing Protocol
The optimal approach is "as-needed" dosing rather than daily maintenance therapy 3, 4:
- Standard dose: 40 mg taken 1 hour before the performance or anxiety-provoking event 5, 6
- Lower dose option: 20 mg for patients concerned about side effects or first-time users 3
- Timing: Administer 30-60 minutes before the anticipated stressor for peak effect 4
The evidence strongly supports single-dose, event-driven use rather than chronic daily dosing for performance anxiety. A study using the SAT as an objective measure demonstrated that 40 mg propranolol taken 1 hour before testing improved scores by 130 points in students with test anxiety 5. Similarly, 40 mg reduced observable anxiety in public speakers within 1-2 hours 6.
Patient Selection: Who Benefits Most
Propranolol works best for performance anxiety when somatic/autonomic symptoms predominate rather than purely cognitive anxiety 1, 4:
- Tremor (most responsive symptom)
- Palpitations and tachycardia
- Sweating
- Shaking
Propranolol is less effective for severe panic attacks or extreme anxiety symptoms 4. It primarily blocks peripheral beta-receptors, so symptoms mediated through beta-stimulation respond best 4.
Critical Safety Warnings
Never prescribe propranolol for chronic daily use in performance anxiety without careful consideration, as abrupt discontinuation after chronic use can precipitate rebound hypertension, tachycardia, or angina 1. The as-needed dosing strategy avoids this risk entirely.
In diabetic patients, propranolol may mask hypoglycemia symptoms (tremor, tachycardia), so counsel these patients accordingly 1.
Common Pitfalls to Avoid
Do not use higher doses thinking they will work better—research paradoxically shows that lower doses (40-80 mg) may be more effective than higher doses (160-320 mg) for anxiety, with some studies showing impaired cognitive function at higher doses 7. One study found that 40 mg and 80 mg improved performance measures more than 160 mg or 320 mg 7.
Avoid combining with nondihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 2.
Monitoring Requirements
For as-needed use in performance anxiety, no routine monitoring between doses is required if the patient is stable and asymptomatic 2. However, counsel patients to monitor for 1:
- Hypotension and dizziness
- Bradycardia (slow heart rate)
- Fatigue
- Cold extremities
If patients inadvertently take higher doses or use propranolol more frequently than intended, monitor more closely for hypotension and bradycardia 1.