Maximum Daily Dose of Propranolol for Performance Anxiety
For performance anxiety, the maximum single dose is 40 mg taken 30-60 minutes before the anxiety-provoking event, and propranolol should not be used as a chronic daily medication for this indication. 1, 2
Situational vs. Chronic Use Distinction
Performance anxiety requires a fundamentally different dosing approach than generalized anxiety:
- Situational/performance anxiety: 10-40 mg as a single dose, taken 30-60 minutes before the triggering event (public speaking, musical performance, test-taking) 1, 2
- Maximum single dose: 40 mg for situational use 1
- Not for chronic daily use: The Japanese Society of Anxiety and Related Disorders specifically states propranolol is not suitable for chronic anxiety treatment in this context 1
When Chronic Dosing Is Considered
If a patient has ongoing anxiety (not purely situational), the dosing paradigm changes entirely:
- Initial dose: 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, 3
- Alternative: Long-acting formulation 80 mg once daily, titrated to 120-160 mg once daily 1
- Maximum reported: While the FDA label mentions doses up to 640 mg daily for other indications 4, and one older study used up to 1200 mg temporarily for severe anxiety 5, the American College of Cardiology recommends 80-160 mg daily as the typical maximum for anxiety 1
Critical Pre-Treatment Screening
Before any propranolol use, exclude these absolute contraindications:
- Second or third-degree heart block 1, 2, 3
- Decompensated heart failure 1, 2, 3
- Asthma or reactive airway disease (can precipitate life-threatening bronchospasm) 1, 2, 3
- Cardiogenic shock 1, 2
- Sinus node dysfunction without pacemaker 1, 2
Patient Selection for Performance Anxiety
Propranolol works best for patients with prominent somatic/autonomic symptoms:
- Tremor, palpitations, tachycardia, sweating 1, 2
- Not effective for predominantly psychological symptoms of anxiety 1
- Most beneficial in mild to moderate situational anxiety 2
Safety Monitoring for As-Needed Use
- No routine monitoring required for occasional as-needed use in healthy patients 2
- Instruct patients to check pulse before taking propranolol and hold the dose if heart rate is below 60 bpm 2
- Monitor for fatigue, dizziness, cold extremities, and bradycardia 2
Special Warnings
- Diabetic patients: Propranolol masks hypoglycemia symptoms, making recognition of low blood sugar difficult 2, 3
- Never combine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to excessive bradycardia and heart block risk 1, 2
- Never abruptly discontinue after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 3
Evidence Quality Note
The distinction between situational and chronic use is critical. While older research from the 1970s-1990s explored higher doses (80-320 mg daily, occasionally up to 1200 mg) 5, 6, 7, contemporary guidelines emphasize that performance anxiety specifically requires only single pre-event doses of 10-40 mg 1, 2. One study in adolescents with test anxiety demonstrated effectiveness with a single 40 mg dose 8.