What is the recommended dosage and precautions for using propranolol (beta blocker) in an adult patient with public speaking anxiety and no significant past medical history of cardiovascular disease, asthma, or diabetes?

Propranolol for Public Speaking Anxiety

Recommended Dosing Protocol

For situational public speaking anxiety in otherwise healthy adults, take propranolol 10-20 mg orally 30-60 minutes before the anxiety-provoking event. 1

• The maximum single dose for situational use is 40 mg 1
• Propranolol is most effective for patients experiencing prominent physical/somatic symptoms such as tremor, palpitations, tachycardia, and sweating rather than predominantly psychological symptoms 1, 2
• This is specifically for situational use only—propranolol is not suitable for chronic daily anxiety treatment 1

Mandatory Pre-Treatment Screening

Before taking even a single dose, you must exclude the following absolute contraindications:

• Asthma or reactive airway disease (propranolol can trigger life-threatening bronchospasm) 1, 3
• Second or third-degree heart block without a pacemaker 1, 3
• Decompensated heart failure or significant left ventricular dysfunction 1, 3
• Sinus node dysfunction without a pacemaker 3
• Cardiogenic shock 3
• Hypotension (systolic BP <100 mmHg) 1

Baseline Assessment Required

• Measure baseline heart rate and blood pressure 1
• Perform cardiovascular examination with auscultation 1
• Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 1
• No routine blood work, ECG, or echocardiogram is required in otherwise healthy adults without cardiac concerns 1

Critical Safety Warnings

For Diabetic Patients

Propranolol masks the warning symptoms of hypoglycemia (tremor, tachycardia, palpitations) and should be used with extreme caution or avoided entirely in patients with diabetes or history of hypoglycemic episodes 1, 3

Drug Interactions to Avoid

• Never combine propranolol with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe risk of bradycardia and heart block 1
• Use caution with other medications that slow heart rate or lower blood pressure 1

Discontinuation Warning

• If using propranolol regularly (not just situationally), never stop abruptly—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1, 3
• For single-dose situational use, this is not a concern 1

Expected Effects and Monitoring

What to Expect

• Propranolol primarily reduces physical symptoms of anxiety: tremor, rapid heartbeat, sweating, and palpitations 1, 2
• It does not significantly affect the psychological/cognitive components of anxiety 2
• Effects begin within 30-60 minutes and last approximately 3-6 hours for immediate-release formulation 1

Common Side Effects

• Fatigue 1
• Bradycardia (slow heart rate) 1
• Hypotension (low blood pressure) 1
• Dizziness 1
• Cold extremities 1

When to Hold the Dose

• Heart rate <50-60 bpm with symptoms (dizziness, lightheadedness) 1
• Systolic blood pressure <100 mmHg with symptoms 1
• Wheezing or difficulty breathing 1
• Significantly reduced oral intake or vomiting 1

Evidence Quality and Context

The recommendation for 10-40 mg situational dosing comes from high-quality guideline evidence 1, supported by older but consistent research showing efficacy for performance anxiety 2, 4, 5. Importantly, propranolol is specifically deprecated for generalized social anxiety disorder but remains effective for discrete situational triggers with prominent somatic symptoms 1.

The evidence shows propranolol works best when anxiety manifests primarily as physical symptoms (tremor, palpitations, sweating) rather than psychological worry 1, 2. Studies from the 1970s-1990s consistently demonstrated benefit for performance anxiety at doses of 20-40 mg 2, 4, 5, though these were not specifically focused on public speaking.

Common Pitfalls to Avoid

• Do not use propranolol for chronic daily anxiety—it is only for situational use 1
• Do not take if you have asthma—this can be life-threatening 1, 3
• Do not assume it will help with psychological worry—it primarily addresses physical symptoms 1, 2
• Do not take on an empty stomach if diabetic—risk of unrecognized hypoglycemia 1
• Do not combine with other heart rate-lowering medications without medical supervision 1