What is the recommended dosing for propranolol (beta blocker) in the management of anxiety?

Propranolol Dosing for Anxiety

For anxiety management, initiate propranolol immediate-release at 20-40 mg once to three times daily (total 20-120 mg/day), targeting patients with predominantly somatic symptoms like tremor, palpitations, and tachycardia, with doses typically not exceeding 160 mg daily for this indication. 1, 2

Patient Selection

Propranolol is most effective for specific anxiety presentations:

• Patients with physical/somatic symptoms (tremor, palpitations, tachycardia, sweating, autonomic symptoms) are most likely to benefit 1, 3
• Performance anxiety or situational anxiety (public speaking, social phobias) responds well to single doses of 20-40 mg taken 30-60 minutes before the event 2
• Patients with predominantly psychic anxiety symptoms (worry, rumination) show less benefit and should be considered for alternative treatments 3

Dosing Regimens

For Generalized Anxiety with Somatic Symptoms

• Starting dose: 20-40 mg once to three times daily 2, 4
• Typical therapeutic range: 80-160 mg daily in divided doses 1, 4
• Maximum dose: Up to 320 mg daily may be required for optimal beta-blockade (abolition of orthostatic and hyperventilatory tachycardia), though doses above 160 mg are rarely needed for anxiety 4
• Long-acting formulation: 80 mg once daily, titrating to 120-160 mg daily if needed 1

For Performance/Situational Anxiety

• Single dose: 20-40 mg taken 30-60 minutes before the anxiety-provoking situation 2

Mandatory Pre-Treatment Assessment

Before initiating propranolol, screen for absolute contraindications 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
• Sinus node dysfunction without pacemaker
• Recent or ongoing hypoglycemic episodes

Baseline assessment should include 1:

• Heart rate and blood pressure measurement
• Cardiovascular examination with auscultation
• History screening for bronchospasm, diabetes, and concurrent medications affecting cardiac conduction

Monitoring Requirements

• During dose escalation: Monitor for hypotension and bradycardia 1
• Stable patients: No routine vital sign monitoring required between appointments if asymptomatic 1
• Watch for common adverse effects: Fatigue, bradycardia, hypotension, dizziness, cold extremities 1

Critical Safety Considerations

Never abruptly discontinue propranolol after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1

Special Populations and Warnings

• Diabetic patients: Propranolol may mask hypoglycemia symptoms; counsel patients accordingly 1
• Elderly patients: May require lower doses due to altered pharmacokinetics 1
• During illness: Hold doses during periods of diminished oral intake or vomiting to prevent hypoglycemia 1
• Drug interactions: Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1

Duration of Treatment

• Efficacy beyond 4 weeks: Clinical benefit for periods longer than 4 weeks remains less well-established in the literature 2
• Long-term use: Some patients have been treated for extended periods (months to years) with sustained benefit and often decreasing dose requirements over time 4
• Remissions: Lasting remissions are not infrequent, allowing for eventual discontinuation 4

Common Pitfalls

The major limitation is that propranolol primarily addresses somatic anxiety symptoms, not psychic symptoms 3. Patients with predominantly psychological anxiety (worry, rumination without significant physical symptoms) should be offered alternative treatments such as SSRIs or cognitive behavioral therapy rather than propranolol 3. Additionally, routine laboratory work (CBC, renal, liver, thyroid function) and ECG are not required in otherwise healthy adults without cardiac concerns 1.