What is the recommended dosage and administration of propranolol for an anxious patient, considering their age, medical history, and potential drug interactions?

Propranolol for Anxiety: Dosing and Administration

For anxiety treatment, start propranolol immediate-release at 40 mg twice daily (80 mg total daily), titrating up to 80-160 mg daily in divided doses based on response, or use propranolol LA 80 mg once daily, increasing to 120-160 mg once daily as needed. 1

Patient Selection and Optimal Candidates

Propranolol works best for patients with prominent somatic/autonomic symptoms rather than purely psychological anxiety. 1, 2 Target patients experiencing:

• Tremor, palpitations, and tachycardia
• Sweating and other autonomic hyperactivity symptoms 1, 2

For situational/performance anxiety (public speaking, specific social phobias), use 10-40 mg taken 30-60 minutes before the anxiety-provoking event. 1, 2 The maximum single dose for situational use is 40 mg. 1

Important distinction: Propranolol is not recommended for generalized social anxiety disorder based on negative evidence, but is highly effective for performance anxiety with prominent somatic symptoms. 1

Mandatory Pre-Treatment Assessment

Before prescribing, you must screen for absolute contraindications: 1, 2

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

Required baseline evaluation: 1, 2

• Heart rate and blood pressure measurement
• Cardiovascular examination with auscultation
• Screen for history of bronchospasm
• Assess for diabetes (propranolol masks hypoglycemia symptoms)
• Review concurrent medications affecting cardiac conduction

Good news for healthy adults: Routine blood work (CBC, renal, liver, thyroid function), ECG, and echocardiogram are NOT required in otherwise healthy patients without cardiac concerns. 1 ECG and echocardiogram are only needed if cardiac abnormalities are suspected. 1

Dosing Regimens by Clinical Scenario

For Ongoing Chronic Anxiety

Immediate-release formulation: 1

• Start: 40 mg twice daily (80 mg total daily)
• Typical effective range: 80-160 mg daily in 2 divided doses
• Can increase up to 320 mg daily if needed
• Dosing frequency: 2-4 times daily due to 3-6 hour half-life 1

Long-acting formulation (Propranolol LA): 1, 3

• Start: 80 mg once daily
• Titrate to: 120-160 mg once daily
• Maximum studied: 640 mg daily (though rarely needed) 3
• Extended-release half-life: 8-20 hours 1

For Performance/Situational Anxiety

• Single dose: 10-20 mg taken 30-60 minutes before event 1
• Maximum single dose: 40 mg 1
• Not suitable for chronic daily use in this context 1

Historical Context from Research

Older studies used higher doses (80-320 mg daily, with some patients requiring up to 1200 mg temporarily for severe symptoms), adjusted to achieve virtual abolition of orthostatic and hyperventilatory tachycardia. 4 However, modern guidelines favor lower starting doses with gradual titration. 1

Monitoring Requirements

During treatment: 1

• Monitor for hypotension and bradycardia, especially during dose escalation
• No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 1

Common adverse effects to counsel patients about: 1, 2

• Fatigue and dizziness
• Bradycardia and hypotension
• Cold extremities
• Potential worsening of heart failure (in susceptible patients)

Critical Safety Warnings

Never abruptly discontinue propranolol, especially after chronic use. 1, 2 This can precipitate:

• Rebound hypertension
• Tachycardia
• Angina 1, 2

Taper gradually over several weeks when discontinuing. 1 For patients on treatment for extended periods, taper over 1-3 weeks depending on dose and duration. 1

Special populations requiring dose adjustment: 1

• Elderly patients: May require lower doses due to altered pharmacokinetics
• Patients with comorbidities: Lower doses may be needed
• Diabetic patients: Propranolol masks hypoglycemia symptoms—counsel patients extensively about this risk 1, 2

Drug Interactions to Avoid

Avoid routine combination with: 1

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
• Reason: Increased risk of severe bradycardia and heart block

Relative Contraindications and Cautions

Use with extreme caution in: 1

• History of bronchospasm
• Diabetes or history of hypoglycemic episodes
• Concurrent medications affecting cardiac conduction

Temporarily discontinue if: 1

• Patient develops wheezing requiring treatment
• Significantly reduced oral intake or vomiting occurs

Clinical Pearls

Propranolol vs. benzodiazepines: Research suggests propranolol is particularly useful for anxiety disorders characterized by somatic symptoms related to increased adrenergic tone, moderate intensity, and recent onset. 5 It avoids the psychomotor impairment and dependence risk of benzodiazepines. 5

Response timeline: Full therapeutic response may take days to several weeks at a given dosage. 3 For chronic anxiety, clinical efficacy beyond 4 weeks of treatment is well-established in long-term studies (some patients treated for over 10 years). 4

Somatic vs. psychic anxiety: Propranolol is significantly more effective than placebo in patients with predominantly somatic anxiety symptoms, but shows minimal benefit in those with primarily psychological symptoms. 6 This distinction is crucial for patient selection.