What is the recommended dosage 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 with 30-60 mg daily in divided doses (e.g., 20 mg twice daily or 30 mg once daily), titrating up to a typical maintenance range of 80-160 mg daily in divided doses. 1, 2

Patient Selection: Who Benefits Most

Propranolol works best for anxiety characterized by physical/somatic symptoms rather than purely psychological worry 1, 2:

• Ideal candidates experience tremor, palpitations, tachycardia, sweating, and other autonomic symptoms 1
• Less effective for cognitive anxiety symptoms or severe panic attacks 3
• The Japanese Society of Anxiety and Related Disorders specifically notes propranolol is effective for performance anxiety and specific situational triggers, but not recommended for generalized social anxiety disorder 1
• Patients with predominantly somatic anxiety respond better than those with primarily psychic anxiety 4

Dosing Regimens

For Situational/Performance Anxiety (As-Needed Use)

• 10-40 mg immediate-release taken 30-60 minutes before the event 1, 2
• Maximum single dose should not exceed 40 mg 1
• This approach is ideal for public speaking, test-taking, or other discrete performance situations 5
• Effects occur within 1-2 hours 3

For Chronic Anxiety Treatment (Regular Daily Use)

• Starting dose: 30-60 mg daily in divided doses (e.g., 20 mg twice daily or 30 mg once daily) 1, 2
• Typical maintenance: 80-160 mg daily in 2 divided doses 2, 6
• Alternative: Extended-release formulation 80 mg once daily, titrating to 120-160 mg daily 1
• Some patients may require 80-320 mg daily for optimal response 6
• Maximum dose can reach 640 mg daily if needed, though this is rarely necessary 1
• Clinical efficacy beyond 4 weeks of treatment requires further demonstration 7

Important caveat: The Japanese Society of Anxiety and Related Disorders suggests propranolol is not suitable for chronic anxiety treatment and should be reserved for situational use 1. However, older research supports longer-term use at higher doses when somatic symptoms are prominent 6, 3.

Mandatory Pre-Treatment Assessment

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

• Second or third-degree heart block
• Decompensated heart failure or significant left ventricular dysfunction
• Asthma or obstructive airway disease
• Cardiogenic shock
• Sinus node dysfunction without pacemaker
• History of hypoglycemic episodes

Baseline 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
• ECG and echocardiogram only needed in patients with suspected cardiac abnormalities 1, 2

Note: Routine blood work (CBC, renal, liver, thyroid function) is not required in otherwise healthy adults 1

Titration Strategy

• Adjust dosing to achieve virtual abolition of orthostatic and hyperventilatory tachycardia 6
• Monitor for hypotension and bradycardia, especially during dose escalation 1, 2
• Lower doses may be required for elderly patients due to altered pharmacokinetics 1, 2
• Titrate cautiously in patients with comorbidities 1

Critical Safety Warnings

Never Abruptly Discontinue

Propranolol must be tapered gradually over several weeks when discontinuing, especially after chronic use 1, 2. Abrupt cessation can precipitate:

• Rebound hypertension
• Tachycardia
• Angina 1

Special Populations

Diabetic patients: Propranolol masks symptoms of hypoglycemia (tremor, tachycardia) 1. Use with extreme caution and counsel patients about this risk 1.

Drug Interactions

Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1, 2

When to Hold Doses

Temporarily discontinue if 1:

• Wheezing requiring treatment develops
• Significantly reduced oral intake or vomiting occurs
• Patient experiences hypotension or severe bradycardia

Monitoring During Treatment

• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
• Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities 1
• Monitor for potential worsening of heart failure, bronchospasm, or severe bradycardia 1
• Administer with food to reduce risk of hypoglycemia 1

Clinical Pearls

• Propranolol requirements often diminish over time, and lasting remissions are not infrequent with chronic use 6
• Depression is evident in 50% of anxious patients and may persist as a lone symptom requiring antidepressant treatment 6
• The mechanism likely involves blocking peripheral beta-receptors rather than central effects, as non-CNS-penetrating beta-blockers also show efficacy 7
• Objective testing demonstrates significant benefit: students with test anxiety showed 130-point improvement in SAT scores with 40 mg propranolol 5