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

Propranolol Dosing for Anxiety

For situational/performance anxiety, use propranolol 10-40 mg taken 30-60 minutes before the anxiety-provoking event, with a maximum single dose of 40 mg. For chronic anxiety with prominent somatic symptoms, start with 80 mg daily in divided doses (immediate-release) or 80 mg once daily (long-acting formulation), titrating up to 120-160 mg daily for maintenance. 1, 2

Patient Selection: Who Benefits Most

Propranolol works best for anxiety characterized by prominent physical/autonomic symptoms rather than purely psychological symptoms: 1, 2

• Tremor
• Palpitations and tachycardia
• Sweating
• Other somatic manifestations of autonomic hyperactivity

The Japanese Society of Anxiety and Related Disorders specifically notes that propranolol is effective for performance anxiety and specific situational triggers but is NOT recommended for generalized social anxiety disorder based on negative evidence. 1

Dosing Regimens

For Situational/Performance Anxiety (As-Needed Use)

• 10-40 mg taken 30-60 minutes before the triggering event 1, 2
• Maximum single dose: 40 mg 1
• No routine monitoring required for occasional use in healthy patients 2
• Patients should check pulse before taking; hold dose if heart rate <60 bpm 2

For Chronic Anxiety Treatment

Immediate-Release Formulation: 1

• Starting dose: 80-160 mg daily in 2 divided doses
• Maintenance: 120-160 mg daily
• Typical effective range: 80-320 mg daily 3
• Maximum: 640 mg daily if needed (rarely required) 1

Long-Acting Formulation: 1

• Starting dose: 80 mg once daily
• Titrate up to 120-160 mg daily for maintenance

Dose Titration Strategy

The key to safe propranolol use is gradual dose escalation by 40-80 mg/day increments to avoid toxic effects including ataxia, falls, and confusion. 1 Adjust dosing to achieve virtual abolition of orthostatic and hyperventilatory tachycardia as a marker of adequate beta-blockade. 3

Mandatory Pre-Treatment Assessment

Before initiating propranolol, screen for absolute contraindications: 1, 2

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

Baseline cardiovascular assessment includes: 1

• Heart rate and blood pressure measurement
• Cardiovascular examination with auscultation
• Screening for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
• ECG and echocardiogram only needed if cardiac abnormalities suspected 1

Important note: Routine blood work (CBC, renal, liver, thyroid function) is NOT required before starting propranolol in otherwise healthy adults. 1

Critical Safety Warnings

Diabetes Patients

Propranolol masks hypoglycemia symptoms, making recognition of low blood sugar difficult. 1, 2 Monitor closely and counsel patients about this risk.

Drug Interactions

Avoid combining propranolol with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to excessive bradycardia and heart block risk. 1, 2

Discontinuation

Never abruptly discontinue propranolol after chronic use. This can precipitate rebound hypertension, tachycardia, or angina. 1 Taper gradually over several weeks when stopping treatment.

Common Adverse Effects

Monitor for: 1

• Fatigue and dizziness
• Bradycardia and hypotension (especially during dose escalation)
• Cold extremities
• Potential worsening of heart failure

Monitoring Requirements

For chronic daily use: 1

• Monitor for hypotension and bradycardia, especially during dose escalation
• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic
• Hold doses during times of diminished oral intake or vomiting 1

For as-needed use: 2

• No routine monitoring required in healthy patients
• Instruct patients to self-check pulse before each dose

Special Populations

Elderly patients may require lower doses due to altered pharmacokinetics. 1 Start conservatively and titrate slowly in this population.

Evidence Quality Note

The dosing recommendations are based primarily on American College of Cardiology and American Heart Association guidelines from 2025. 1, 2 Older research from the 1970s-1980s supports the 80-320 mg daily range for chronic anxiety 3, 4, with one study showing efficacy with doses as low as 20 mg for perioperative anxiolysis. 5 However, the most recent guideline evidence prioritizes 10-40 mg for situational use and 80-160 mg daily for chronic treatment. 1, 2