What is the recommended dosing regimen for propranolol (beta-blocker) in a patient with anxiety, without contraindications such as asthma, Chronic Obstructive Pulmonary Disease (COPD), or significant cardiovascular disease?

Propranolol Dosing for Anxiety

For anxiety without cardiovascular contraindications, start propranolol immediate-release 40 mg twice daily (80 mg total daily), titrating up to 80-160 mg daily in divided doses based on response, or use long-acting formulation 80 mg once daily, titrating to 120-160 mg daily. 1

Initial Dosing Strategy

Immediate-release formulation:

• Start with 40 mg twice daily (80 mg total daily) 1
• Typical effective range: 80-160 mg daily in 2 divided doses 1
• Maximum maintenance dose: 40-160 mg daily in divided or single dose with long-acting formulations 2

Long-acting formulation:

• Start with 80 mg once daily 1
• Titrate to 120-160 mg once daily as needed 1
• Allows for simplified once-daily dosing with extended half-life of 8-20 hours 1

Situational vs. Chronic Anxiety

For situational/performance anxiety only:

• Use 10-20 mg taken 30-60 minutes before the anxiety-provoking event 1
• Maximum single dose: 40 mg 1
• Most effective for patients with prominent somatic symptoms (tremor, palpitations, sweating) rather than psychological symptoms 1
• Not suitable for chronic daily anxiety treatment 1

For ongoing generalized anxiety:

• Requires regular daily dosing with immediate-release (twice daily) or long-acting (once daily) formulations 1
• The evidence for generalized anxiety disorder is weaker than for situational anxiety 3

Mandatory Pre-Treatment Assessment

Absolute contraindications to exclude:

• Second or third-degree heart block 2, 1
• Decompensated heart failure or signs of low output state 2, 1
• Active asthma or reactive airway disease 2, 1
• Cardiogenic shock 1
• Sinus node dysfunction without pacemaker 1
• Severe hypotension 2

Baseline cardiovascular assessment:

• Measure heart rate and blood pressure 1
• Perform cardiovascular examination with auscultation 1
• Screen for history of bronchospasm 1
• Assess for diabetes and risk of hypoglycemia 1
• Review concurrent medications affecting cardiac conduction 1

Note: Routine ECG and echocardiogram are not required in otherwise healthy adults without cardiac concerns 1

Titration and Monitoring

Dose escalation:

• Monitor for hypotension and bradycardia, especially during dose escalation 1
• Adjust doses based on symptom control and tolerability 1
• Elderly patients may require lower doses due to altered pharmacokinetics 1

Ongoing monitoring:

• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1
• Watch for common adverse effects: fatigue, bradycardia, hypotension, dizziness, cold extremities 1

Critical Safety Warnings

Never abruptly discontinue propranolol:

• Taper gradually over several weeks when discontinuing 1
• Abrupt cessation can precipitate rebound hypertension, tachycardia, or angina 1

Special populations requiring caution:

• Diabetic patients: propranolol masks symptoms of hypoglycemia 1
• Use with extreme caution in patients with history of hypoglycemic episodes 1

Drug interactions:

• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 1

Evidence Quality and Clinical Context

The evidence for propranolol in anxiety is mixed. A 2025 systematic review found no evidence for beneficial effect compared to placebo or benzodiazepines in social phobia or panic disorder 3. However, older studies from the 1970s-1990s suggested benefit for somatic symptoms of anxiety 4, 5. The most recent guideline-based recommendations support its use primarily for situational anxiety with prominent physical symptoms (tremor, palpitations, tachycardia) rather than generalized anxiety disorder 1.

Common pitfall: Propranolol is often prescribed for generalized anxiety, but the strongest evidence supports its use for performance/situational anxiety with somatic symptoms 1, 3. For chronic generalized anxiety disorder, SSRIs remain first-line 6.