What is the maximum daily dose of propanolol (beta blocker) for a healthy adult with performance anxiety?

Maximum Daily Dose of Propranolol for Performance Anxiety

For performance anxiety in healthy adults, propranolol should be used situationally at 10-40 mg taken 30-60 minutes before the anxiety-provoking event, rather than as a daily medication. 1, 2

Situational (As-Needed) Dosing for Performance Anxiety

• Single-dose range: 10-40 mg taken 30-60 minutes before the performance or event 1, 2
• The maximum single dose for situational anxiety is 40 mg 2
• Propranolol is most effective when used for specific situational triggers with prominent somatic symptoms (tremor, palpitations, tachycardia, sweating) rather than for chronic daily anxiety 2, 3
• Clinical effect occurs within 1-2 hours of administration 4

Daily Dosing (If Chronic Treatment Is Considered)

If you are considering chronic daily treatment rather than situational use:

• Initial dose: 40 mg twice daily (80 mg total daily) 1
• Typical effective range: 80-160 mg daily in 2 divided doses 1, 5
• Maximum maintenance dose: 160 mg daily for anxiety, though some sources cite up to 320 mg daily for severe cases 1, 6
• Absolute maximum: 640 mg daily (FDA-approved maximum for all indications, though rarely needed for anxiety) 1

However, propranolol is not recommended for chronic daily treatment of generalized anxiety—it is specifically indicated for performance anxiety and situational use 2. The Japanese Society of Anxiety and Related Disorders explicitly deprecates propranolol for generalized social anxiety disorder based on negative evidence 1.

Critical Pre-Treatment Assessment

Before prescribing propranolol, you must screen for absolute contraindications:

• Second or third-degree heart block 1, 2
• Decompensated heart failure 1, 5
• Asthma or reactive airway disease (can precipitate life-threatening bronchospasm) 1, 2
• Cardiogenic shock or severe hypotension 1, 2
• Sinus node dysfunction without pacemaker 1, 2

Baseline assessment should include:

• Heart rate and blood pressure measurement 1
• Cardiovascular examination with auscultation 1
• Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 1

Monitoring for As-Needed Use

• No routine monitoring required for occasional as-needed use in healthy patients 2
• Instruct patients to check their pulse before taking propranolol and hold the dose if heart rate is below 60 bpm 2
• Monitor for adverse effects: fatigue, dizziness, cold extremities, bradycardia 2

Critical Safety Warnings

• Never use in patients with asthma—propranolol can cause life-threatening bronchospasm 2
• In diabetic patients, propranolol masks hypoglycemia symptoms, making recognition of low blood sugar difficult 2
• Avoid combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to excessive bradycardia and heart block risk 1, 2, 7
• Never abruptly discontinue after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 5

Common Pitfalls to Avoid

• Do not prescribe propranolol for daily use when situational dosing would suffice—performance anxiety is best treated with as-needed dosing 2
• Do not exceed 40 mg for a single situational dose—higher doses do not improve efficacy for performance anxiety and may increase side effects 2
• Some evidence suggests that lower doses (40-80 mg) may be more effective than higher doses (160-320 mg) for central effects related to anxiety 8
• Propranolol efficacy for anxiety beyond 4 weeks of continuous treatment remains unproven 3