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

Propranolol Dosing for Anxiety

For situational/performance anxiety, take 10-40 mg of immediate-release propranolol 30-60 minutes before the anxiety-provoking event; for chronic anxiety with prominent somatic symptoms, start at 30-60 mg daily in divided doses and titrate up to 80-160 mg daily as needed. 1

Dosing Strategy Based on Anxiety Type

Situational/Performance Anxiety (As-Needed Use)

• Take 10-40 mg immediate-release propranolol 30-60 minutes before the triggering event (e.g., public speaking, musical performance) 1
• This approach is most effective for patients experiencing tremor, palpitations, sweating, and other autonomic symptoms during specific situations 1
• The Japanese Society of Anxiety and Related Disorders specifically endorses this as-needed approach for performance anxiety, with a maximum single dose of 40 mg 2
• Clinical effect is typically noted within 1-2 hours 3

Chronic Anxiety with Somatic Symptoms (Regular Dosing)

• Start with 30-60 mg daily in divided doses (e.g., 20-30 mg twice daily) 2, 1
• Titrate to 80-160 mg daily in 2 divided doses for maintenance (e.g., 40-80 mg twice daily) 2, 1
• Higher doses up to 320 mg daily may be required for optimal symptom control, though doses up to 640 mg daily are occasionally used 2, 4
• Extended-release formulations can be dosed once daily starting at 80 mg, titrating to 120-160 mg 2, 1
• Improvement with chronic dosing may take several weeks at higher doses (e.g., 160 mg/day) 3

Patient Selection: Who Benefits Most

Propranolol is most effective for patients with prominent physical/somatic symptoms of anxiety rather than purely psychological symptoms 2, 1, 5:

• Tremor, palpitations, tachycardia, sweating, and other autonomic hyperactivity symptoms 2, 5
• Performance anxiety with observable physical manifestations 6
• Propranolol is NOT recommended for generalized social anxiety disorder or predominantly cognitive/psychological anxiety 2, 5

Mandatory Pre-Treatment Screening

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

• Second or third-degree heart block
• Decompensated heart failure or significant left ventricular dysfunction
• Asthma or obstructive airway disease (reactive airways disease)
• Cardiogenic shock or severe hypotension
• Sinus node dysfunction without pacemaker
• Recent or ongoing hypoglycemic episodes

Perform baseline assessment 2, 1:

• Measure heart rate and blood pressure
• Cardiovascular examination with auscultation
• Screen for history of bronchospasm, diabetes, and medications affecting cardiac conduction
• ECG and echocardiogram are NOT routinely required in otherwise healthy adults, only in patients with suspected cardiac abnormalities 2

Critical Safety Considerations

Monitoring During Treatment

• Watch for hypotension and bradycardia, especially during dose escalation 2, 1
• No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic 2
• Monitor diabetic patients for masked hypoglycemia symptoms 2

Discontinuation Protocol

• Never abruptly discontinue propranolol after chronic use 2, 1
• Taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 2, 1

Drug Interactions to Avoid

• Do not routinely combine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block 2, 1

Dosing Adjustments and Special Considerations

• Elderly patients require lower starting doses due to altered pharmacokinetics; start at the lower end of the dosing range and titrate cautiously 2, 1
• Administer with food to reduce risk of hypoglycemia 2
• Hold doses during periods of diminished oral intake or vomiting 2
• Propranolol requirements often diminish over time, and lasting remissions are not infrequent with chronic use 4

Common Pitfalls to Avoid

• Do not use propranolol as first-line for generalized anxiety disorder or panic disorder with predominantly psychological symptoms—it works best for somatic manifestations 2, 5
• Do not prescribe for chronic daily use in situational anxiety—as-needed dosing is more appropriate 2
• Do not forget to assess for asthma/reactive airway disease, as propranolol can precipitate life-threatening bronchospasm 2, 1
• Do not combine with other medications that slow heart rate without careful monitoring 2, 1