What is the recommended dose of beta (beta blockers) blockers, such as propranolol (propranolol) or atenolol (atenolol), for anxiety management?

Beta-Blocker Dosing for Anxiety

Beta-blockers are NOT recommended as first-line treatment for chronic anxiety disorders, but propranolol 10-40 mg taken as-needed 30-60 minutes before anxiety-provoking situations is the most appropriate use for performance anxiety and situational anxiety with prominent somatic symptoms. 1, 2

Clinical Context and Evidence Quality

The most recent high-quality guideline evidence from the Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology (2023) explicitly deprecates beta-blockers (both atenolol and propranolol) for social anxiety disorder based on negative evidence, recommending SSRIs and SNRIs as first-line therapy instead. 1 This represents a significant shift from older literature and should guide contemporary practice.

When Beta-Blockers May Be Appropriate

Beta-blockers work best for anxiety characterized by prominent somatic/autonomic symptoms such as tremor, palpitations, tachycardia, and sweating in patients with mild to moderate situational anxiety. 2 They are most useful for:

• Performance anxiety (e.g., public speaking, musical performance) where symptoms are predictable and time-limited 3, 4
• Situational anxiety of recent onset not meeting DSM criteria for chronic anxiety disorders 3
• Patients in whom somatic symptoms have not responded adequately to benzodiazepines 5

Specific Dosing Recommendations

Propranolol (Most Studied Agent)

For as-needed/situational use:

• 20-40 mg taken once, 30-60 minutes before the anxiety-provoking event 3, 4
• Single doses up to 40 mg have been studied for performance anxiety 3

For scheduled dosing (if continuous treatment attempted):

• 20-40 mg once to three times daily 3
• Higher doses up to 160 mg/day have been studied for longer-term treatment (several weeks), though efficacy beyond 4 weeks is not well-established 3, 4

Atenolol (Alternative Agent)

• 25-100 mg once daily for chronic dosing 1
• Recent preliminary data suggests atenolol may be better tolerated than propranolol, with 86% of patients reporting positive effects and 100% of patients who tried both preferring atenolol over propranolol 6
• Atenolol has the advantage of once-daily dosing due to longer half-life 7

Critical Safety Contraindications

Absolute contraindications that must be screened before prescribing: 2

• Asthma or reactive airway disease (can precipitate life-threatening bronchospasm per American Heart Association) 1, 2
• Second or third-degree heart block 2
• Decompensated heart failure 2
• Significant left ventricular dysfunction 2
• Cardiogenic shock 2
• Severe hypotension 2
• Sinus node dysfunction without pacemaker 2

Important warnings:

• In diabetic patients, propranolol may mask hypoglycemia symptoms, making recognition of low blood sugar difficult 2
• Avoid combination with non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to excessive bradycardia and heart block risk 2

Monitoring for As-Needed Use

For occasional as-needed use in healthy patients: 2

• No routine monitoring required per American Academy of Family Physicians 2
• Patients should check their pulse before taking propranolol and hold the dose if heart rate is below 60 bpm 2
• Monitor for adverse effects including fatigue, dizziness, cold extremities, and bradycardia 2

Common Pitfalls and Clinical Pearls

Key limitations to communicate to patients:

• Clinical efficacy beyond 4 weeks of continuous use has not been demonstrated 3
• Beta-blockers are most effective when symptoms are not extreme in degree—they help mild tremor better than severe panic attack shaking 4
• Improvement occurs within 1-2 hours with relatively low doses 4
• Potential for cognitive impairment and depressive states in predisposed patients remains controversial 3

Practical approach:

• Start with propranolol 10-20 mg as a test dose to assess tolerability before recommending 40 mg for actual performance situations
• Reserve for specific, predictable anxiety-provoking situations rather than chronic daily use
• Consider atenolol 25-50 mg once daily if scheduled dosing is preferred, given better tolerability profile 6
• If anxiety persists or worsens despite beta-blocker trial, transition to evidence-based first-line therapy (SSRIs/SNRIs) or cognitive behavioral therapy 1