Propranolol Dosing for Anxiety
For adults with anxiety, start propranolol immediate-release at 40 mg twice daily (80 mg total daily), titrating to an effective range of 80-160 mg daily in divided doses, or use propranolol LA 80 mg once daily, titrating to 120-160 mg once daily. 1
Patient Selection and Contraindications
Before prescribing propranolol, you must exclude absolute contraindications:
- Second or third-degree heart block 1
- Decompensated heart failure 1
- Asthma or obstructive airway disease 1
- Cardiogenic shock 1
- Sinus node dysfunction without a pacemaker 1
- Recent or ongoing hypoglycemic episodes 1
Propranolol works best for patients with prominent somatic/autonomic symptoms including tremor, palpitations, tachycardia, sweating, and other physical manifestations of anxiety rather than purely psychological symptoms. 1, 2
Mandatory Pre-Treatment Assessment
Perform these evaluations before initiating propranolol:
- Baseline 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
Routine blood work (CBC, renal, liver, thyroid function) is NOT required in otherwise healthy adults. 1 ECG and echocardiogram are only needed if cardiac concerns exist. 1
Dosing Regimens
For Ongoing Anxiety (Chronic Use)
Immediate-Release Formulation:
- Start at 40 mg twice daily (80 mg total daily) 1
- Typical effective range: 80-160 mg daily in 2 divided doses 1, 3
- Maximum dose: up to 320 mg daily for most patients 3, though some may require up to 640 mg daily 1
- Dosing frequency: 2-4 times daily 1
Long-Acting Formulation (Propranolol LA):
For Situational/Performance Anxiety
For specific anxiety-provoking events (public speaking, performance anxiety):
- 10-20 mg taken 30-60 minutes before the event 1
- Maximum single dose: 40 mg 1
- This approach is effective for situational triggers with prominent somatic symptoms but is NOT suitable for chronic anxiety treatment 1
Monitoring Requirements
During dose escalation, monitor for:
No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic. 1
Critical Safety Warnings
Never abruptly discontinue propranolol, especially after chronic use. 1 Abrupt cessation can precipitate:
Taper gradually over several weeks when discontinuing. 1
In diabetic patients, propranolol masks symptoms of hypoglycemia (tremor, tachycardia), making hypoglycemia detection difficult. Use with extreme caution in patients with diabetes or history of hypoglycemic episodes. 1
Common Adverse Effects
Patients may experience:
- Fatigue 1
- Bradycardia 1
- Hypotension 1
- Dizziness 1
- Cold extremities 1
- Potential worsening of heart failure 1
Drug Interactions
Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block. 1
Special Populations
Elderly patients may require lower doses due to altered pharmacokinetics. 1
Evidence Quality and Context
The dosing recommendations are based on American College of Cardiology and American Heart Association guidelines. 1 Historical research supports that propranolol at 80-320 mg daily effectively controls somatic and psychic symptoms of anxiety 3, with therapeutic benefit appearing within 1-2 hours at relatively low doses (40 mg/day) for acute situations 2, while longer treatment with higher doses (160 mg/day) may provide benefit after several weeks. 2
The key distinction is that propranolol is most effective when somatic symptoms predominate rather than purely cognitive anxiety symptoms. 4, 2 It acts primarily by blocking peripheral beta-adrenergic receptors, directly reducing symptoms like tremor and palpitations. 4