Propranolol Dosing for Performance Anxiety
For performance anxiety, take 10-40 mg of immediate-release propranolol 30-60 minutes before the anxiety-provoking event, with most patients responding well to a single 40 mg dose. 1, 2
Pre-Treatment Screening (Mandatory)
Before prescribing propranolol, you must exclude the following absolute contraindications:
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or obstructive airway disease
- Cardiogenic shock
- Sinus node dysfunction without a pacemaker
- History of hypoglycemic episodes 1, 2
Perform a baseline assessment including heart rate and blood pressure measurement, cardiovascular examination with auscultation, and screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction. 1, 2
Dosing Strategy
As-Needed (Situational) Dosing
- Start with 10-20 mg taken 30-60 minutes before the performance or anxiety-provoking event 1
- Most patients require 40 mg for optimal effect 2, 3
- Maximum single dose should not exceed 40 mg 1
- Effects begin within 1-2 hours 4
When Chronic Treatment Is Needed
If situational dosing proves insufficient and regular treatment is required:
- Start at 30-60 mg daily in divided doses 2
- Can titrate up to 80-160 mg daily in 2 divided doses if needed 2
- Clinical efficacy beyond 4 weeks of continuous treatment remains uncertain 5
Patient Selection: Who Benefits Most
Propranolol is most effective for patients with prominent somatic/physical symptoms of anxiety rather than cognitive symptoms: 1, 2
- Tremor
- Palpitations
- Tachycardia
- Sweating
- Other autonomic hyperactivity symptoms
The Japanese Society of Anxiety and Related Disorders specifically recommends propranolol for performance anxiety and specific situational triggers, but deprecates it for generalized social anxiety disorder. 1
Critical Safety Warnings
Drug Interactions
Never combine propranolol routinely with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block. 1, 2
Special Populations
In diabetic patients, propranolol masks symptoms of hypoglycemia and should be used with extreme caution. 1 Monitor blood glucose more frequently if prescribing to diabetics.
Discontinuation
Never abruptly discontinue propranolol after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina. 1, 2
Monitoring During Treatment
- Monitor for hypotension and bradycardia, especially during dose escalation 1, 6
- No routine vital sign monitoring required between appointments if the patient is stable and asymptomatic 2
- Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities 1
Common Pitfalls to Avoid
Do not prescribe propranolol for predominantly cognitive/psychological anxiety symptoms—it works on physical symptoms only. 2 Patients with racing thoughts, worry, and psychological distress without significant somatic symptoms will not benefit.
Do not use propranolol as first-line treatment for chronic generalized anxiety—it is specifically indicated for situational/performance anxiety. 1
Evidence Quality Note
The dosing recommendations are supported by multiple guideline sources including the American Heart Association and American College of Cardiology 1, 2, with objective evidence from a controlled study showing 130-point improvement in SAT scores with 40 mg propranolol in students with test anxiety 3. The consensus across studies from the 1970s-1990s consistently supports the 20-40 mg single-dose range for performance anxiety 5, 4, 7, 8.