What is the maximum frequency of propranolol (beta blocker) doses per day for a patient with performance anxiety?

Maximum Daily Frequency of Propranolol for Performance Anxiety

For performance anxiety, propranolol immediate-release can be taken up to 3-4 times daily, with typical dosing of 10-40 mg per dose, though most patients use it as a single dose 30-60 minutes before the anxiety-provoking event. 1, 2

Dosing Framework by Use Pattern

As-Needed/Situational Use (Most Common for Performance Anxiety)

• Single pre-event dose: 10-20 mg taken 30-60 minutes before the performance or anxiety-provoking situation 1
• Maximum single dose: 40 mg for situational anxiety 1
• This approach is specifically recommended for performance anxiety with prominent somatic symptoms like tremor, palpitations, and sweating 2, 3

Chronic/Regular Dosing (If Needed for Ongoing Anxiety)

• Immediate-release formulation: 2-4 times daily dosing is standard 1
• Starting dose: 40 mg twice daily (80 mg total daily) 1
• Typical effective range: 80-160 mg daily divided into 2-4 doses 1, 3
• Maximum reported: Up to 320 mg daily for anxiety (some studies report up to 1200 mg temporarily for severe symptoms, though this is exceptional) 4

Critical Dosing Considerations

Pharmacokinetic Rationale

The immediate-release formulation has a half-life of 3-6 hours, which necessitates multiple daily doses when used chronically 1. However, for performance anxiety specifically, single pre-event dosing is most appropriate and effective 1, 2.

Important Caveats

• Performance anxiety is situational: The Japanese Society of Anxiety and Related Disorders explicitly states propranolol is not suitable for chronic anxiety treatment but rather for situational use 1
• Efficacy beyond 4 weeks unclear: Clinical efficacy of beta-blockers administered for periods longer than 4 weeks remains to be demonstrated for anxiety 3
• Lower doses often sufficient: Average therapeutic doses range from 20-40 mg, once to three times daily for anxiety disorders 3

Pre-Dose Safety Check for As-Needed Use

Patients should check their pulse before taking propranolol and hold the dose if heart rate is below 60 bpm 2. This is particularly important when using multiple doses in a day.

Absolute Contraindications

Never use propranolol in patients with: second or third-degree heart block, decompensated heart failure, asthma or reactive airway disease, cardiogenic shock, severe hypotension, or sinus node dysfunction without a pacemaker 1, 2.

Special Warning for Diabetics

Propranolol masks hypoglycemia symptoms, making recognition of low blood sugar difficult—use with extreme caution in diabetic patients 1, 2.

Practical Algorithm for Performance Anxiety

For isolated performance events:

• Use 10-40 mg as a single dose 30-60 minutes before the event 1, 2
• Maximum frequency: Can be used for multiple events in a day if needed, but monitor cumulative dose and heart rate 1

For frequent performance situations requiring daily dosing:

• Start with 40 mg twice daily (morning and afternoon/evening) 1
• Can increase to 3-4 times daily if needed, staying within 80-320 mg total daily dose 1, 3
• Avoid evening doses if insomnia occurs 5