What alternatives are available for a 16-year-old male experiencing abdominal pain on propranolol (beta-blocker) 20mg and inadequate anxiety relief on sertraline (SSRI) 150mg qhs (every night at bedtime)?

Management of Propranolol-Induced Abdominal Pain and Inadequate Anxiety Control on Sertraline

Discontinue propranolol immediately and increase sertraline to 200mg daily, as beta-blockers lack robust evidence for anxiety disorders and may be causing the abdominal pain, while sertraline at 150mg is below the maximum FDA-approved dose of 200mg for anxiety disorders. 1, 2

Propranolol Discontinuation Rationale

Beta-blockers are not effective for generalized anxiety disorders and should not be used routinely. The most recent systematic review and meta-analysis (2025) found no evidence for beneficial effects of beta-blockers compared with placebo in patients with anxiety disorders (p ≥0.54 for all comparisons). 2

• Propranolol may actually induce depression and should be used cautiously—if at all—in anxiety patients, particularly adolescents. 3
• The abdominal pain is likely medication-related and warrants immediate discontinuation. 3, 2
• Historical data show propranolol provides minimal benefit in chronic anxiety, with therapeutic effects difficult to distinguish from side effects like dizziness and fatigue. 4

Sertraline Optimization Strategy

Increase sertraline from 150mg to 200mg daily, as this remains within FDA-approved dosing and addresses the inadequate anxiety response. 1

• The FDA label for sertraline indicates doses up to 200mg daily are approved for anxiety disorders including panic disorder, social anxiety disorder, and PTSD. 1
• SSRIs like sertraline are recommended as gut-brain neuromodulators for functional gastrointestinal symptoms, making them particularly appropriate if the abdominal pain persists after propranolol discontinuation. 5
• Monitor closely for serotonin syndrome symptoms (agitation, tremor, autonomic instability, GI symptoms) during dose escalation, particularly in the first 24-48 hours. 1

Alternative Anxiolytic Considerations if Sertraline Fails at Maximum Dose

If sertraline 200mg remains ineffective after 8-12 weeks, switch to a tricyclic antidepressant (TCA) such as amitriptyline 10-25mg at bedtime. 6

• TCAs demonstrate superior efficacy for anxiety-related abdominal pain compared to SSRIs, with proven benefit in IBS-related anxiety and chronic pain syndromes. 6
• Low-dose amitriptyline (10mg at bedtime) has demonstrated efficacy and is well-tolerated in adolescents for both anxiety and functional GI symptoms. 6
• For adolescents specifically, propranolol, amitriptyline, or topiramate are guideline-recommended preventive options, but given propranolol's failure and GI side effects, amitriptyline is the logical next choice. 6

Critical Monitoring Parameters

Screen for bipolar disorder risk before escalating antidepressant therapy, as adolescents are at higher risk for mood conversion. 1

• Obtain detailed psychiatric history including family history of bipolar disorder, suicide, and depression before dose escalation. 1
• Monitor for manic episodes: greatly increased energy, severe insomnia, racing thoughts, reckless behavior, excessive happiness or irritability. 1
• Watch for new or worsening suicidal thoughts, particularly in the first few months after dose changes in adolescents. 1

Gastrointestinal Symptom Management

If abdominal pain persists after propranolol discontinuation, consider adding an antispasmodic such as hyoscine or dicyclomine for symptomatic relief. 6

• Antispasmodics reduce smooth muscle contraction and visceral hypersensitivity, providing relief for functional abdominal pain (RR 0.67; 95% CI 0.55-0.80). 6
• These agents are particularly useful for postprandial symptoms and can be used as needed rather than scheduled dosing. 6

Common Pitfalls to Avoid

• Do not abruptly discontinue sertraline if considering a switch—taper by no more than 10-25% every 2-4 weeks to avoid withdrawal syndrome (anxiety, irritability, electric shock-like sensations, GI symptoms). 5, 1
• Do not assume all abdominal pain is functional—rare cases of SSRI-induced pancreatitis have been reported with sertraline, though this typically presents with severe pain and elevated amylase. 7
• Do not combine multiple serotonergic agents without careful monitoring for serotonin syndrome, particularly if considering augmentation strategies. 1