What is the recommended dosage of propranolol (beta-blocker) for an adult patient with anxiety and no significant cardiovascular history?

Propranolol Dosing for Anxiety in Adults

For anxiety in adults without cardiovascular disease, start propranolol immediate-release at 10-20 mg taken 30-60 minutes before anxiety-provoking situations for performance/situational anxiety, or 40 mg twice daily (80 mg total daily) for more generalized anxiety symptoms, titrating up to 80-160 mg daily in divided doses based on response. 1, 2

Patient Selection and Contraindications

Before prescribing propranolol for anxiety, you must exclude several absolute contraindications:

• Second or third-degree heart block 1
• Decompensated heart failure or significant left ventricular dysfunction 1
• Asthma or reactive airway disease 1
• Cardiogenic shock 1
• Sinus node dysfunction without a pacemaker 1
• Recent or ongoing hypoglycemic episodes 1

Propranolol works best for patients with prominent somatic/physical symptoms of anxiety including tremor, palpitations, tachycardia, and sweating—not primarily for psychological symptoms. 1, 2

Dosing Regimens by Anxiety Type

Situational/Performance Anxiety (Most Common Use)

Start with 10-20 mg taken 30-60 minutes before the anxiety-provoking event, with a maximum single dose of 40 mg. 1 This approach is supported by evidence showing propranolol is most effective for specific situational triggers rather than chronic generalized anxiety. 1

Generalized Anxiety Symptoms

For ongoing anxiety requiring daily treatment:

• Initial dose: 40 mg twice daily (80 mg total daily) of immediate-release propranolol 3, 2
• Titration: Increase gradually based on response 2
• Typical effective range: 80-160 mg daily in 2 divided doses 3, 2
• Maximum studied dose: Up to 320 mg daily, though most patients respond to lower doses 2, 4

A landmark study of 513 anxiety patients found that 80-320 mg daily sufficed for most patients, with dosage adjusted to achieve virtual abolition of orthostatic and hyperventilatory tachycardia. 2

Alternative: Long-Acting Formulation

Propranolol LA (long-acting): 80 mg once daily, can titrate to 120-160 mg once daily 3, 1

Pre-Treatment Assessment

Perform a focused cardiovascular assessment before initiating therapy:

• Measure baseline heart rate and blood pressure 1
• Cardiac auscultation to detect murmurs or arrhythmias 1
• Screen for history of bronchospasm 1
• Ask about diabetes and hypoglycemic episodes (propranolol masks hypoglycemia symptoms) 1
• Review concurrent medications affecting cardiac conduction 1

Routine ECG, echocardiogram, or laboratory work is NOT required in otherwise healthy adults without cardiac concerns. 1

Monitoring During Treatment

• Monitor for hypotension and bradycardia, especially during dose escalation 1
• 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, 4

Critical Safety Warnings

Never Abruptly Discontinue

Propranolol must be tapered gradually over several weeks when discontinuing to prevent rebound hypertension, tachycardia, or angina. 1 Abrupt cessation can precipitate serious cardiovascular events. 3, 1

Diabetes Caution

Propranolol masks symptoms of hypoglycemia (tremor, tachycardia) in diabetic patients—use with extreme caution and counsel patients accordingly. 1

Drug Interactions

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

Comparative Evidence

A double-blind trial comparing propranolol (80-320 mg/day) to chlordiazepoxide and placebo in 212 anxiety patients found:

• At Week 1: Both propranolol and chlordiazepoxide superior to placebo 4
• At Week 2: Only propranolol remained superior to placebo 4
• Propranolol had fewer premature discontinuations due to adverse effects than chlordiazepoxide (4 vs 7 patients) 4
• Chlordiazepoxide caused more fatigue, drowsiness, and libido changes 4

Special Populations

Elderly patients may require lower doses due to altered pharmacokinetics. 1 Start at the lower end of the dosing range and titrate cautiously.

Patients with severe liver disease (albumin <30 g/L) should start with very low doses (20 mg of conventional formulation three times daily or 80 mg slow-release daily) and be monitored closely, as propranolol concentrations can be markedly elevated. 5

Common Pitfalls

• Using propranolol for primarily psychological anxiety symptoms rather than somatic symptoms—it works best for physical manifestations. 1, 2
• Underdosing: Many patients require 160-320 mg daily for optimal anxiety control, not just 40-80 mg. 2, 4
• Forgetting to screen for asthma/COPD: This is an absolute contraindication. 1
• Not counseling diabetic patients about masked hypoglycemia symptoms. 1
• Abrupt discontinuation: Always taper over 1-3 weeks minimum. 1