What is the current evidence for using Propranolol (beta blocker) for daily anxiety management?

From the Guidelines

Propranolol is not typically recommended for daily anxiety management due to its limited efficacy in addressing the psychological components of anxiety and its potential side effects.

Key Points

• Propranolol is a beta-blocker that is primarily used to treat physical symptoms of anxiety, such as tremors and palpitations, rather than the psychological components of anxiety 1.
• It may be prescribed off-label for performance anxiety or social anxiety disorders, but its use for daily anxiety management is limited due to its potential side effects, such as lethargy, depression, dizziness, exercise intolerance, hypotension, and sleep disorders 1.
• The efficacy of propranolol in reducing anxiety symptoms is often short-lived and may not address the underlying causes of anxiety, making it a less desirable option for long-term daily management.
• More effective and targeted treatments, such as selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines, are available for daily anxiety management.
• Propranolol's beneficial effects on symptoms of exertional dyspnea and exercise intolerance appear to be attributable largely to a decrease in the heart rate with a consequent prolongation of diastole and relaxation and an increase in passive ventricular filling 1.

Dosage and Administration

• The usual dose of propranolol for anxiety management is not established, but it has been used in doses ranging from 20 to 40 mg per day for performance anxiety 1.
• In patients with hypertension, propranolol may be administered orally, with initial doses ranging from 40 to 80 mg per day, and maintenance doses of up to 100 mg twice daily 1.

Side Effects and Contraindications

• Propranolol's potential side effects include fatigue, impotence, sleep disturbances, and chronotropic incompetence 1.
• It is contraindicated in patients with asthma, diabetes, bradycardia, and congestive heart failure, and should be used with caution in patients with chronic obstructive pulmonary disease or a history of chronic obstructive pulmonary disease 1.

The FDA Drug Labels for propranolol (PO) do not address this question.

From the Research

Current Evidence for Propranolol in Daily Anxiety Management

• The current evidence for using propranolol (beta blocker) for daily anxiety management is limited and inconclusive 2, 3.
• A systematic review and meta-analysis of randomized controlled trials found no statistically significant differences between the efficacy of propranolol and benzodiazepines in the short-term treatment of panic disorder with or without agoraphobia 2.
• Another study found that atenolol, a different beta-blocker, may be well-tolerated and effective among persons with anxiety disorders, with 86% of patients reporting a positive effect and continuing to take atenolol 4.
• However, the evidence for beta-blockers in general, including propranolol, is insufficient to support their routine use in the treatment of anxiety disorders 2, 3.
• A recent systematic review and meta-analysis found no evidence for a beneficial effect of beta-blockers compared with either placebo or benzodiazepines in patients with social phobia or panic disorder with/without agoraphobia 3.

Limitations and Future Directions

• Many of the included studies had small sample sizes, missing data, and high or unclear risk of bias 3.
• There is a need for large, rigorously controlled empirical studies to further substantiate the claim that beta-blockers, including propranolol, are effective and safe for anxiety disorders 4, 3.
• Further research is needed to understand when and why practitioners are using beta-blockers for anxiety, and to provide definitive evidence of their effectiveness 3.