Can Inderal (propranolol) be used to treat anxiety?

Propranolol (Inderal) for Anxiety

Propranolol is effective for performance anxiety and situational anxiety with prominent physical symptoms, but it is not recommended as first-line therapy for generalized anxiety disorder or panic disorder. 1, 2

When to Use Propranolol

Best clinical applications:

• Performance anxiety (stage fright): Take 20-40 mg as a single dose 1 hour before the anxiety-provoking event 1
• Situational public speaking anxiety: Effective for isolated, infrequent events where physical symptoms (tremor, palpitations, rapid heart rate) interfere with performance 1, 3
• Anxiety with prominent somatic symptoms: Most effective when cardiovascular manifestations (palpitations, tachycardia, tremor) dominate the clinical picture 4, 5

Important practice point: Have patients take a trial dose before an important event to assess individual response and tolerability 1

When NOT to Use Propranolol

Propranolol should NOT be used for:

• Generalized anxiety disorder: SSRIs (escitalopram, sertraline, fluvoxamine, paroxetine) or SNRIs (venlafaxine) are first-line 2, 6
• Panic disorder: Not effective for panic attacks; SSRIs remain first-line 6, 5
• Chronic social anxiety disorder: Canadian guidelines specifically deprecate propranolol for this indication; SSRIs/SNRIs are preferred 1, 2
• Frequent or chronic performance anxiety: CBT is first-line; if pharmacotherapy is needed chronically, use SSRIs/SNRIs, not beta-blockers 1

Absolute Contraindications

Do not prescribe propranolol in patients with:

• Asthma or chronic obstructive pulmonary disease 1
• Bradycardia or heart block 1
• Decompensated heart failure 1
• Severe hypotension or cardiogenic shock 1

Mechanism and Efficacy

• Propranolol blocks peripheral beta-adrenergic receptors, reducing adrenaline's effects on heart rate, tremor, and nervousness 1, 5
• Works within 1-2 hours of administration 5
• Most effective for symptoms mediated through beta-stimulation (tremor, palpitations) rather than psychological anxiety 4, 5
• Studies show effectiveness in up to 70% of patients with essential tremor, and similar efficacy for performance-related tremor 1

Dosing Strategy

For situational anxiety:

• Single dose: 20-40 mg taken 1 hour before the event 1
• Not for chronic daily therapy in performance anxiety 1

For ongoing somatic anxiety symptoms (if SSRIs fail):

• Start with 40 mg/day in divided doses 3, 5
• Can increase to 160 mg/day if needed for longer-term treatment 5
• Clinical efficacy beyond 4 weeks is not well-established 3

Important Precautions

• Diabetes: May mask hypoglycemia symptoms; use with caution 1
• Discontinuation: Never stop abruptly after regular use due to rebound symptoms 1
• Common side effects: Bradycardia, hypotension, fatigue, cold extremities, sleep disturbances 1
• Depression risk: Use cautiously in patients with concurrent depressive illness 6

Clinical Algorithm for Anxiety Treatment

Step 1 - Characterize the anxiety:

• Situational/performance anxiety with physical symptoms → Consider propranolol 1, 4
• Generalized anxiety disorder → Start SSRI/SNRI 2
• Panic disorder → Start SSRI, not propranolol 6
• Chronic social anxiety → Start SSRI/SNRI, not propranolol 1, 2

Step 2 - For situational anxiety:

• Screen for contraindications (asthma, heart block, bradycardia, heart failure) 1
• Prescribe propranolol 20-40 mg to take 1 hour before event 1
• Advise trial dose before important event 1

Step 3 - For chronic anxiety with residual somatic symptoms:

• Start SSRI/SNRI as first-line 2
• If somatic symptoms persist despite adequate SSRI trial, consider adding low-dose propranolol (40 mg/day) 3, 6
• Combine with CBT for optimal outcomes 1

Common Pitfalls to Avoid

• Do not use propranolol as monotherapy for panic disorder - it is ineffective and may delay appropriate treatment 6
• Do not prescribe for chronic social anxiety - negative evidence supports avoiding this practice 2
• Do not forget to screen for asthma/COPD - this is an absolute contraindication 1
• Do not use chronically for performance anxiety - reserve for situational use only; chronic cases need CBT or SSRIs 1