Propranolol Dosing for Anxiety
For situational/performance anxiety, use propranolol 10-40 mg immediate-release taken 30-60 minutes before the anxiety-provoking event; for chronic anxiety with prominent somatic symptoms, start 30-60 mg daily in divided doses (or 80 mg extended-release once daily), titrating up to a typical maintenance range of 80-160 mg daily. 1, 2
Patient Selection: Who Benefits Most
Propranolol is most effective for patients experiencing physical/somatic symptoms of autonomic hyperactivity—tremor, palpitations, tachycardia, sweating—rather than those with predominantly psychological or cognitive anxiety symptoms. 1, 3 The Japanese Society of Anxiety and Related Disorders specifically deprecates propranolol for generalized social anxiety disorder based on negative evidence, but endorses it for performance anxiety and specific situational triggers with prominent somatic symptoms. 1
Dosing Strategies
For Situational/Performance Anxiety (As-Needed Use)
- 10-40 mg immediate-release taken 30-60 minutes before the triggering event (maximum single dose 40 mg). 1, 2
- This approach is supported by objective evidence: students with test anxiety who took 40 mg propranolol one hour before the SAT scored 130 points higher than their baseline performance (p<0.01). 4
- A perioperative study found 20 mg propranolol provided significant anxiety reduction with minimal side effects compared to 40 mg, which caused more bradycardia (25%) and hypotension (10%). 5
For Chronic Anxiety Treatment
- Start with 30-60 mg daily in divided doses (immediate-release) or 80 mg once daily (extended-release formulation). 1, 2
- Titrate to 80-160 mg daily for maintenance, adjusting to achieve optimal clinical response and virtual abolition of orthostatic and hyperventilatory tachycardia. 1, 2
- Long-term clinical experience shows that 80-320 mg daily typically suffices, though some patients with unusually intense symptoms temporarily required up to 1200 mg daily. 6
- Propranolol is NOT suitable for chronic treatment of generalized anxiety—reserve it for situational use or patients with predominantly somatic symptoms. 1
Mandatory Pre-Treatment Assessment
Before initiating propranolol, screen for absolute contraindications: 1, 2
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or obstructive airway disease
- Cardiogenic shock
- Sinus node dysfunction without pacemaker
- History of hypoglycemic episodes
Baseline cardiovascular assessment should include: 1, 2
- Heart rate and blood pressure measurement
- Cardiovascular examination with auscultation
- History screening for bronchospasm, diabetes, and concurrent medications affecting cardiac conduction
Important caveat: Routine blood work (CBC, renal, liver, thyroid function) is NOT required before starting propranolol in otherwise healthy adults, and ECG/echocardiogram are only needed in selected cases with cardiac concerns. 1
Monitoring During Treatment
- Monitor for hypotension and bradycardia, especially during dose escalation. 1, 2
- No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic. 1
- Common adverse effects include fatigue, bradycardia, hypotension, dizziness, cold extremities, and potential worsening of heart failure. 1
- In diabetic patients, propranolol may mask symptoms of hypoglycemia—counsel accordingly. 1, 7
Critical Safety Considerations
Never abruptly discontinue propranolol after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina. 1, 2 This is a common pitfall that can precipitate serious cardiovascular complications.
Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block. 1, 2
Administer with food to reduce the risk of hypoglycemia, and hold doses during times of diminished oral intake or vomiting. 1, 7
Special Populations
Elderly patients may require lower doses due to altered pharmacokinetics—start at the lower end of the dosing range and titrate cautiously. 1, 2
Evidence Quality Note
The guideline recommendations are strongly supported by the American College of Cardiology and American Heart Association. 1, 2 While older research studies from the 1970s-1980s used higher doses (up to 320 mg daily or more), modern practice favors lower starting doses with careful titration. 6, 8 The distinction between somatic versus psychic anxiety as a predictor of response has been consistently validated across multiple studies. 3