In a healthy adult without asthma, COPD, bradycardia, AV block, heart failure, hypotension, or severe depression, can propranolol be used to treat performance‑related anxiety and what is the appropriate starting dose and contraindications?

Propranolol for Performance-Related Anxiety

Propranolol is highly effective for performance-related anxiety and can be safely used in healthy adults without the listed contraindications, with a typical starting dose of 20-40 mg taken 30-60 minutes before the anxiety-provoking event. 1

Patient Selection and Mechanism

Propranolol works by blocking peripheral beta-adrenergic receptors, thereby reducing the physical manifestations of anxiety—tremor, palpitations, tachycardia, and sweating—rather than addressing the psychological components. 2 This makes it particularly suited for situational performance anxiety (stage fright, public speaking, test-taking) where somatic symptoms predominate. 1

• Patients most likely to benefit are those experiencing prominent autonomic symptoms such as tremor, rapid heartbeat, and sweating during specific performance situations. 1
• Propranolol is not recommended for chronic generalized anxiety disorder or panic disorder, where SSRIs/SNRIs are first-line. 2

Mandatory Pre-Treatment Screening

Before prescribing propranolol, you must exclude the following absolute contraindications: 1, 3

• Second or third-degree heart block
• Decompensated heart failure or cardiogenic shock
• Asthma or obstructive airway disease (propranolol is non-selective and blocks β-2 receptors, risking bronchospasm) 4, 2
• Sinus bradycardia or sinus node dysfunction without a pacemaker
• Hypotension
• Known hypersensitivity to propranolol

Baseline assessment should include heart rate and blood pressure measurement, cardiovascular auscultation, and screening for history of bronchospasm, diabetes, and medications affecting cardiac conduction. 1 Routine ECG, echocardiogram, or laboratory work is not required in otherwise healthy adults with unremarkable cardiac history and examination. 1

Dosing Strategy

For Situational/Performance Anxiety

The recommended approach is a single dose of 20-40 mg of immediate-release propranolol taken 60 minutes (range 30-60 minutes) before the performance or anxiety-provoking event. 1, 2 This is not chronic daily therapy. 2

• The maximum single dose for situational use is 40 mg. 2
• Advise the patient to trial the dose before an important event to assess individual response and tolerability. 2
• Propranolol should be taken with food to reduce the risk of hypoglycemia. 1

For Ongoing Anxiety (if chronic treatment is needed)

If the patient requires daily treatment rather than situational use, the dosing differs: 1

• Start with 40 mg twice daily (80 mg total daily) of immediate-release propranolol
• Typical effective range is 80-160 mg daily in 2 divided doses
• Alternatively, propranolol LA (long-acting) can be initiated at 80 mg once daily, titrated to 120-160 mg once daily

However, for chronic anxiety, SSRIs/SNRIs combined with cognitive behavioral therapy are first-line, not propranolol. 2

Critical Safety Warnings

Hypoglycemia Risk

Propranolol masks the typical adrenergic warning signs of hypoglycemia (tremor, rapid heartbeat, palpitations), making it particularly concerning for diabetic patients or those with a history of hypoglycemic episodes. 1, 2

• Patients with diabetes should use propranolol with extreme caution and increase frequency of blood glucose monitoring. 2
• Instruct patients to rely on non-adrenergic cues such as hunger, confusion, or sweating to detect low blood sugar. 1
• Always administer propranolol with food. 1

Cardiovascular Monitoring

Monitor for signs of excessive beta-blockade, including: 1

• Heart rate below 50 beats/min
• Systolic blood pressure below 90 mmHg
• Dizziness, marked fatigue, or lightheadedness
• New or worsening shortness of breath or wheezing

Discontinuation

Never abruptly discontinue propranolol after regular use, as this can precipitate rebound hypertension, tachycardia, or angina. 1, 2 When stopping chronic therapy, taper gradually over 1-3 weeks. 1

Drug Interactions

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

Common Pitfalls

• Using propranolol for chronic generalized anxiety: The evidence does not support routine use for generalized anxiety disorder or panic disorder. 5, 6 Reserve it for situational performance anxiety with prominent somatic symptoms.
• Forgetting to screen for asthma/COPD: Even mild reactive airway disease is a contraindication due to the risk of bronchospasm from β-2 blockade. 4, 2
• Not counseling diabetic patients: The masking of hypoglycemia symptoms is a serious risk that requires explicit patient education and more frequent glucose monitoring. 2
• Prescribing without a trial dose: Individual response varies; patients should test the medication before a critical performance. 2

Practical Algorithm

1. Screen for absolute contraindications (heart block, heart failure, asthma, bradycardia, hypotension). 1, 3
2. Measure baseline heart rate and blood pressure. 1
3. For isolated, infrequent performance anxiety: Prescribe 20-40 mg immediate-release propranolol to take 60 minutes before the event, with food. 1, 2
4. For frequent performance anxiety: Consider cognitive behavioral therapy as first-line; if pharmacotherapy is needed chronically, use SSRIs/SNRIs, not beta-blockers. 2
5. Counsel on hypoglycemia risk if diabetic, and advise taking with food. 1, 2
6. Recommend a trial dose before an important event. 2