In a healthy adult with performance‑related anxiety, how should propranolol be dosed, what are its contraindications, and what alternative treatments are available?

Propranolol for Performance-Related Anxiety

Mechanism and Dosing

For situational performance anxiety, propranolol 20–40 mg taken 1 hour before the anxiety-provoking event is the recommended approach. 1 The drug works by blocking peripheral β-adrenergic receptors, thereby reducing somatic manifestations of anxiety such as rapid heart rate, tremor, sweating, and palpitations—without directly affecting the central psychological components of anxiety. 1, 2

Practical Dosing Strategy

• Single-dose regimen: 20–40 mg of immediate-release propranolol taken 60 minutes before the performance or public speaking event. 1
• Trial dose: Advise the patient to test this dose before an important event to assess individual response and tolerability, as some patients may experience excessive fatigue or dizziness. 1
• Not for chronic use: Propranolol is not recommended for generalized or chronic social anxiety disorder; SSRIs or SNRIs are first-line for those conditions. 1, 2

For patients requiring ongoing treatment (e.g., frequent performance situations), the typical starting dose is 40 mg twice daily (80 mg total daily), with a usual effective range of 80–160 mg daily in divided doses. 1 However, cognitive behavioral therapy (CBT) is superior to pharmacotherapy for chronic performance anxiety and should be considered first-line in that context. 1

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Absolute Contraindications

Screen carefully for the following before prescribing propranolol:

• Asthma or chronic obstructive pulmonary disease: Non-selective β-blockade can precipitate life-threatening bronchospasm. 1, 2
• Second- or third-degree heart block (without a pacemaker). 1, 2
• Sinus bradycardia or sinus node dysfunction (without a pacemaker). 1, 2
• Decompensated heart failure or cardiogenic shock. 1, 2
• Severe hypotension. 1, 2

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Mandatory Pre-Treatment Assessment

Before prescribing propranolol, perform the following:

• Cardiovascular screening: Measure baseline heart rate and blood pressure; auscultate the heart for murmurs or irregular rhythms. 1
• Pulmonary history: Ask specifically about any history of wheezing, bronchospasm, or reactive airway disease. 1
• Diabetes screening: Propranolol masks adrenergic warning signs of hypoglycemia (tremor, tachycardia), so patients with diabetes or a history of hypoglycemic episodes require counseling to rely on non-adrenergic cues (hunger, sweating, confusion) and to increase blood glucose monitoring frequency. 1, 2
• Medication review: Identify concurrent use of non-dihydropyridine calcium-channel blockers (diltiazem, verapamil), which markedly increase the risk of severe bradycardia and heart block when combined with propranolol. 1

Routine laboratory work (CBC, renal, liver, thyroid function) and ECG are not required in otherwise healthy adults without cardiac concerns. 1

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Common and Serious Adverse Effects

Common Side Effects

• Bradycardia, hypotension, fatigue, dizziness, cold extremities, and sleep disturbances. 1, 2
• These effects are dose-dependent and usually mild at the 20–40 mg single-dose range used for situational anxiety. 1

Serious Adverse Effects

• Bronchospasm: Can be life-threatening in patients with reactive airway disease. 1, 2
• Severe bradycardia or heart block: Monitor for heart rate <50 bpm or new symptoms of dizziness and syncope. 1
• Masking of hypoglycemia: Particularly dangerous in diabetic patients; educate them to monitor glucose more frequently. 1, 2
• Rebound hypertension, tachycardia, or angina: Can occur if propranolol is abruptly discontinued after regular use; always taper gradually over 1–3 weeks. 1, 2

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Monitoring During Treatment

• For single-dose situational use: No routine monitoring is required between doses. 1
• For chronic or frequent use: Check heart rate and blood pressure at follow-up visits; discontinue if heart rate falls below 50 bpm, systolic blood pressure drops below 90 mmHg, or new wheezing/shortness of breath develops. 1
• Diabetic patients: Review blood glucose logs regularly, especially after dose adjustments. 1

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Alternative Treatments

Non-Pharmacological Approaches

• Cognitive behavioral therapy (CBT): First-line for chronic performance anxiety; superior long-term outcomes compared to propranolol. 1, 2
• Relaxation techniques and adequate preparation: Can be combined with propranolol for situational anxiety. 1

Pharmacological Alternatives

• SSRIs or SNRIs: First-line for generalized social anxiety disorder or chronic performance anxiety requiring daily treatment. 1, 2
• Benzodiazepines: May be considered for acute anxiety requiring sedation, but carry risks of psychomotor impairment and dependence; propranolol is preferred for somatic symptoms. 3
• Buspirone: An alternative anxiolytic for chronic anxiety, though not specifically for performance anxiety. 3

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Clinical Pearls and Pitfalls

• Patient selection is key: Propranolol is most effective for patients whose anxiety manifests primarily as somatic symptoms (tremor, palpitations, sweating) rather than purely psychological symptoms (worry, rumination). 1, 3, 4
• Avoid abrupt discontinuation: Even after short-term regular use, taper over 1–3 weeks to prevent rebound hypertension or tachycardia. 1, 2
• Drug interactions: Never combine propranolol routinely with diltiazem or verapamil due to additive cardiac conduction effects. 1
• Take with food: Reduces the risk of hypoglycemia, especially in patients who have not eaten recently. 1
• Cognitive effects: Some older studies suggest propranolol may impair recall of difficult memory tasks in anxious individuals, though this remains controversial. 5

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Summary Algorithm for Propranolol Use in Performance Anxiety

1. Screen for contraindications: Asthma, heart block, bradycardia, heart failure, severe hypotension. 1, 2
2. Assess baseline vitals: Heart rate and blood pressure; auscultate heart and lungs. 1
3. Prescribe 20–40 mg immediate-release propranolol to be taken 1 hour before the event. 1
4. Advise a trial dose before an important performance to assess tolerability. 1
5. Counsel on adverse effects: Dizziness, fatigue, bradycardia; instruct to hold dose if feeling unwell or experiencing wheezing. 1
6. For chronic anxiety: Refer for CBT or consider SSRIs/SNRIs instead of daily propranolol. 1, 2
7. If discontinuing after regular use: Taper gradually over 1–3 weeks. 1, 2