What is the recommended dosage of propranolol (Selective Beta-Blocker) and diazepam (Benzodiazepine) for a patient with Generalized Anxiety Disorder (GAD)?

Dosing Propranolol and Diazepam for Generalized Anxiety Disorder

Neither propranolol nor diazepam should be used as first-line treatment for GAD—SSRIs (escitalopram 10-20 mg/day or sertraline 50-200 mg/day) or SNRIs (duloxetine 60-120 mg/day or venlafaxine 75-225 mg/day) are the evidence-based first-line pharmacological treatments. 1

Why These Agents Are Not Recommended for GAD

Propranolol

• Beta-blockers including propranolol are not supported for routine use in GAD based on negative evidence from controlled trials 1, 2
• Propranolol showed no significant benefit for panic attacks or core anxiety symptoms in GAD patients 2, 3
• The only potential role is as an adjunct for residual somatic symptoms (palpitations, tachycardia) when combined with standard treatment, though evidence is weak 2
• Critical warning: Propranolol may induce depression and should be avoided in patients with concurrent depressive illness 2

Diazepam

• Benzodiazepines are not recommended for chronic anxiety treatment in GAD due to risks of dependence, tolerance, withdrawal, and cognitive impairment 4, 1
• While diazepam shows initial efficacy in the first 2-3 weeks (particularly for somatic symptoms), antidepressants demonstrate superior efficacy from week 3 onward for core psychic symptoms of tension, apprehension, and worry 5
• Abrupt discontinuation after 6 weeks produces rebound anxiety 6
• Regular use leads to tolerance, addiction, depression, cognitive impairment, and paradoxical agitation in approximately 10% of patients 4

If These Medications Must Be Used (Against Guidelines)

Diazepam Dosing (FDA-Approved)

For anxiety management: 7

• Initial dose: 2-10 mg orally 2-4 times daily depending on symptom severity
• Geriatric or debilitated patients: Start 2-2.5 mg once or twice daily, increase gradually as tolerated
• Discontinuation: Use gradual taper to reduce withdrawal risk; if withdrawal reactions develop, pause taper or increase to previous dose level, then decrease more slowly 7

Propranolol Considerations

• No established dosing regimen exists for GAD as efficacy is not demonstrated 2
• Historical studies used propranolol only in combination with benzodiazepines, not as monotherapy 8
• One older study suggested the combination of propranolol with diazepam was more effective than diazepam alone, but only when propranolol reduced resting pulse rate by >7.5 beats per minute 8

The Evidence-Based Alternative Approach

Start with an SSRI or SNRI: 1

• Escitalopram: 5-10 mg daily initially, titrate by 5-10 mg every 1-2 weeks to target 10-20 mg/day
• Sertraline: 25-50 mg daily initially, titrate by 25-50 mg every 1-2 weeks to target 50-200 mg/day
• Duloxetine: 30 mg daily for one week, then 60-120 mg/day
• Venlafaxine XR: 75-225 mg/day (requires blood pressure monitoring)

Expected timeline: Statistically significant improvement by week 2, clinically significant improvement by week 6, maximal benefit by week 12 1

Combine with cognitive behavioral therapy (CBT) for optimal outcomes, as combination treatment provides superior results compared to medication alone 1

Critical Pitfalls to Avoid

• Do not use benzodiazepines as chronic treatment—reserve only for short-term crisis management (days to weeks, not months) 1
• Do not use propranolol as monotherapy for GAD—it lacks efficacy for core anxiety symptoms 2
• Do not abruptly discontinue diazepam—always use gradual taper to prevent withdrawal and rebound anxiety 7, 6
• Do not substitute beta-blockers or benzodiazepines for evidence-based first-line treatments without attempting SSRIs/SNRIs first 1