Propranolol Dosing for Panic Attacks
For panic attacks, propranolol is NOT recommended as a primary treatment, but if used for residual somatic symptoms (palpitations, tremor, tachycardia), the dose is 10-40 mg taken 30-60 minutes before anticipated triggers for situational anxiety, or 40 mg twice daily (80 mg total daily) for ongoing physical symptoms, with a typical effective range of 80-160 mg daily in divided doses. 1, 2
Evidence Quality and Clinical Context
The evidence for propranolol in panic disorder is notably weak. A 2025 systematic review and meta-analysis found no evidence for beneficial effect of beta-blockers in panic disorder or social phobia compared to placebo or benzodiazepines 3. Historical research from 1987 concluded that propranolol's efficacy in panic disorder "has not been widely researched, but preliminary results have not been encouraging" 4.
Propranolol works best for situational/performance anxiety with prominent somatic symptoms (tremor, palpitations, sweating) rather than panic disorder itself 1, 2, 5. The Japanese Society of Anxiety and Related Disorders specifically deprecates propranolol for generalized social anxiety disorder based on negative evidence 1.
Dosing Regimens
For Situational/Performance Anxiety (Preferred Use):
- 10-20 mg taken 30-60 minutes before the anxiety-provoking event 1
- Maximum single dose: 40 mg 1
- This is the most appropriate use case for propranolol in anxiety-related conditions 2
For Ongoing Physical Symptoms of Anxiety (If Used):
- Initial: 40 mg twice daily (80 mg total daily) of immediate-release formulation 1
- Typical effective range: 80-160 mg daily in 2 divided doses 1
- Alternative: Propranolol LA (long-acting) 80 mg once daily, titrated to 120-160 mg once daily 1
- One older study used mean doses of 182 mg daily, though this is higher than typically recommended 6
Formulation Considerations:
- Immediate-release: Half-life 3-6 hours, requires 2-4 times daily dosing 1, 7
- Extended-release: Half-life 8-20 hours, allows once daily dosing 1, 7
Mandatory Pre-Treatment Assessment
Before prescribing propranolol, you must screen for absolute contraindications: 1, 2, 7
- Second or third-degree heart block
- Decompensated heart failure
- Asthma or obstructive airway disease
- Cardiogenic shock
- Sinus node dysfunction without pacemaker
- Significant left ventricular dysfunction
Baseline assessment should include: 1
- Heart rate and blood pressure measurement
- Cardiovascular examination with auscultation
- Screening for history of bronchospasm
- Assessment for diabetes (propranolol masks hypoglycemia symptoms)
- Review of concurrent medications affecting cardiac conduction
The American College of Cardiology states that routine blood work (CBC, renal, liver, thyroid function) is NOT required before starting propranolol in otherwise healthy adults, and ECG/echocardiogram are only needed in selected cases with cardiac concerns 1.
Critical Safety Warnings
Hypoglycemia Risk:
- Propranolol masks symptoms of hypoglycemia in diabetic patients 1, 2
- Administer with food to reduce hypoglycemia risk 1
- Hold doses during times of diminished oral intake or vomiting 1, 2
Discontinuation:
- NEVER abruptly discontinue propranolol after chronic use 1
- Taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1
Monitoring:
- Monitor for hypotension and bradycardia, especially during dose escalation 1, 7
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
Drug Interactions:
- Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1
Common Adverse Effects
Patients should expect: 1
- Fatigue
- Bradycardia
- Hypotension
- Dizziness
- Cold extremities
- Potential worsening of heart failure
Beta-blockers may induce depression and should be used cautiously in panic patients with concurrent depressive illness 4.
Clinical Pitfalls
The most common mistake is using propranolol as primary treatment for panic disorder itself - the evidence does not support this 3. Propranolol may provide symptomatic relief for residual somatic complaints when combined with the patient's ongoing drug regimen (such as SSRIs or benzodiazepines), but it is not a standalone panic disorder treatment 4, 8.
Propranolol is effective within 1-2 hours for acute somatic symptoms 5, making it suitable for situational use, but effects are on physical symptoms (tremor, heart racing) rather than psychological worry 2.
Lower doses may be required in elderly patients due to altered pharmacokinetics 1.