What is the recommended dose and frequency of propranolol (beta blocker) for an adult patient with anxiety?

Propranolol Dosing for Anxiety

For ongoing anxiety with prominent physical symptoms (tremor, palpitations, sweating), start propranolol immediate-release 40 mg twice daily (80 mg total daily), and titrate up to 80-160 mg daily in 2 divided doses based on symptom response. 1

Patient Selection

Propranolol works best for patients with somatic/autonomic symptoms rather than purely psychological anxiety:

• Tremor, palpitations, tachycardia, sweating are the target symptoms 1
• Less effective for patients with predominantly psychological worry or panic symptoms 2
• Particularly useful for performance anxiety and situational triggers 1, 3

Dosing Regimens

For Chronic/Ongoing Anxiety

• Start: 40 mg twice daily (immediate-release) 1
• Typical effective range: 80-160 mg daily in 2 divided doses 1, 4
• Alternative: Propranolol LA (long-acting) 80 mg once daily, titrate to 120-160 mg once daily 1
• Maximum reported: Up to 320 mg daily may be needed for some patients 4, 5

For Situational/Performance Anxiety

• Single dose: 10-20 mg taken 30-60 minutes before the anxiety-provoking event 1
• Maximum single dose: 40 mg 1, 6
• This is for specific situations (public speaking, performances), not chronic treatment 1

Mandatory Pre-Treatment Screening

Check for absolute contraindications before prescribing: 1, 3

• Second or third-degree heart block
• Decompensated heart failure
• Asthma or obstructive airway disease
• Cardiogenic shock or severe hypotension
• Sinus node dysfunction without pacemaker

Baseline assessment required: 1

• Measure heart rate and blood pressure
• Cardiovascular examination with auscultation
• Screen for history of bronchospasm
• Screen for diabetes (propranolol masks hypoglycemia symptoms)

Monitoring During Treatment

• Monitor heart rate and blood pressure during dose escalation 1
• No routine monitoring required between appointments if patient is stable and asymptomatic 1
• Watch for hypotension, bradycardia, fatigue, dizziness, cold extremities 1

Critical Safety Warnings

Never abruptly discontinue propranolol after chronic use—this causes rebound hypertension, tachycardia, or angina. Taper gradually over 1-3 weeks when stopping. 1, 7

Diabetic patients: Propranolol masks hypoglycemia symptoms (tremor, tachycardia). Use with extreme caution and counsel patients about this risk. 1, 3

Give with food to reduce hypoglycemia risk, especially in patients with irregular eating patterns. 3, 7

Hold doses if patient has vomiting or significantly reduced oral intake. 3, 7

Drug Interactions to Avoid

Do not routinely combine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil)—this increases risk of severe bradycardia and heart block. 1, 7

Timeline for Effect

• Situational use: Effects occur within 30-60 minutes of single dose 1
• Chronic use: Immediate relief of somatic symptoms, but full benefit may take several weeks at higher doses 5
• Physical symptoms (tremor, palpitations) improve faster than psychological symptoms 2

Common Pitfalls

• Underdosing: Many patients need 80-160 mg daily, not just 40 mg 1, 4
• Wrong patient selection: Propranolol doesn't work well for pure psychological anxiety or severe panic attacks 2, 5
• Abrupt discontinuation: Always taper to prevent rebound symptoms 1, 7
• Ignoring contraindications: Always screen for asthma, heart block, and heart failure before prescribing 1, 3