What is the maximum daily dosage of propanolol (beta blocker) for a patient with performance anxiety?

Maximum Daily Dosage of Propranolol for Performance Anxiety

For performance anxiety (situational anxiety), the maximum single dose is 40 mg taken 30-60 minutes before the anxiety-provoking event, and propranolol is not intended for chronic daily dosing in this specific indication. 1, 2

Situational vs. Chronic Anxiety Dosing

Performance Anxiety (Situational Use)

• Propranolol is specifically effective for performance anxiety and situational triggers with prominent somatic symptoms (tremor, palpitations, sweating), not for generalized social anxiety disorder. 1
• The recommended approach is 10-20 mg taken 30-60 minutes before the performance or anxiety-provoking event, with a maximum single dose of 40 mg. 1
• This is not suitable for chronic daily treatment—propranolol for performance anxiety should be used only as needed for specific situations. 1

Chronic Anxiety Treatment (If Applicable)

If the clinical picture involves ongoing anxiety rather than purely situational performance anxiety, the dosing paradigm changes entirely:

• Initial dosing: 40 mg twice daily (80 mg total daily) of immediate-release propranolol. 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
• Absolute maximum: 640 mg daily if needed, though this is rarely required for anxiety. 1

Critical Distinction in Your Clinical Approach

The question specifically asks about "performance society" (performance anxiety), which is a situational indication. For this specific use:

• Do not prescribe chronic daily dosing—this contradicts the evidence-based approach for performance anxiety. 1
• The 40 mg single-dose maximum applies to situational use only. 1
• Patients should take the medication only before specific performance situations, not as a standing daily regimen. 1

Mandatory Pre-Treatment Screening

Before prescribing any dose of propranolol, screen for absolute contraindications:

• Second or third-degree heart block, decompensated heart failure, asthma/obstructive airway disease, cardiogenic shock, sinus node dysfunction without pacemaker. 1, 2
• Baseline heart rate and blood pressure measurement is required. 1
• Screen for diabetes or history of hypoglycemic episodes—propranolol masks hypoglycemia symptoms and should be used with extreme caution in these patients. 1, 2

Patient Counseling for Performance Anxiety

• Advise patients to take propranolol with or after food to reduce hypoglycemia risk. 2
• Counsel that effects target physical symptoms (tremor, heart racing) rather than psychological worry. 2
• Instruct patients to avoid taking propranolol if experiencing vomiting or diminished oral intake. 2
• Timing is critical: 30-60 minutes before the performance for optimal effect. 1

Common Pitfall to Avoid

Do not confuse performance anxiety dosing with chronic anxiety treatment dosing. The evidence clearly distinguishes these as separate clinical scenarios with different dosing strategies. 1 Prescribing chronic daily propranolol for purely situational performance anxiety represents overtreatment and exposes patients to unnecessary risks of adverse effects including hypotension, bradycardia, and fatigue. 1