Propranolol Dosing for Acute Anxiety Attacks
For acute anxiety attacks with prominent somatic symptoms (tremor, palpitations, sweating), use propranolol 10-40 mg as a single dose taken 30-60 minutes before an anticipated anxiety-provoking event, with a maximum single dose of 40 mg. 1
Situational (Performance-Type) Anxiety Dosing
Propranolol is most effective for situational anxiety with physical manifestations rather than chronic generalized anxiety. 1, 2
Single-Dose Regimen for Acute Episodes
- Starting dose: 10-20 mg taken 30-60 minutes before the anxiety-provoking event 1
- Maximum single dose: 40 mg 1
- Onset of action: 1-2 hours, providing symptom relief during the critical performance window 2
When Chronic Daily Dosing May Be Considered
If anxiety attacks occur frequently (multiple times per week), consider:
- Immediate-release: 40 mg twice daily (80 mg total daily), titrating to 80-160 mg daily in divided doses 1, 3
- Long-acting formulation: 80 mg once daily, titrating to 120-160 mg daily 1, 3
- Higher doses (up to 320 mg daily) may be required for severe or refractory symptoms, though most patients respond to 80-160 mg daily 4, 2
Mandatory Pre-Treatment Screening
Before prescribing any dose of propranolol, you must exclude absolute contraindications: 1
Absolute Contraindications
- Second- or third-degree heart block (without pacemaker) 1
- Decompensated heart failure or severe left ventricular dysfunction 1
- Asthma or obstructive airway disease (risk of life-threatening bronchospasm) 1
- Cardiogenic shock 1
- Sinus node dysfunction or sinus bradycardia (without pacemaker) 1
- Severe hypotension 1
Required Baseline Assessment
- Measure heart rate and blood pressure 1
- Perform cardiovascular examination with auscultation 1, 3
- Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 1
Critical Safety Warnings
Hypoglycemia Risk
Propranolol masks adrenergic warning signs of hypoglycemia (tremor, tachycardia, sweating) in diabetic patients or those prone to low blood sugar. 1 Patients must:
- Monitor blood glucose more frequently 1
- Rely on non-adrenergic cues (hunger, confusion, sweating) to detect hypoglycemia 1
- Take propranolol with food to reduce hypoglycemia risk 1
Drug Interactions
Never combine propranolol routinely with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe risk of bradycardia and heart block. 1, 3
Discontinuation Protocol
Never abruptly stop propranolol after regular use—taper gradually over 1-3 weeks to prevent rebound hypertension, tachycardia, or angina. 1 This applies even to patients using it intermittently if they have taken it regularly for several weeks.
Monitoring for Excessive Beta-Blockade
Watch for signs of excessive effect, especially after the first dose or dose increases: 1
- Dizziness or light-headedness 1
- Marked fatigue 1
- Heart rate below 50 beats/min 1
- Systolic blood pressure below 90 mmHg 1
- New or worsening shortness of breath or wheezing 1
Patient Selection: Who Benefits Most
Propranolol works best for patients whose anxiety manifests primarily as physical/somatic symptoms: 1, 2
Patients with predominantly psychological symptoms (worry, rumination, fear) without prominent physical manifestations are less likely to benefit. 2 The drug blocks peripheral beta-receptors, reducing somatic symptoms, but has limited direct effect on central psychological anxiety. 2
Common Pitfalls to Avoid
Do not use propranolol for severe panic attacks with extreme shaking or overwhelming autonomic symptoms—it is most effective for mild-to-moderate somatic anxiety. 2
Do not expect immediate relief of chronic anticipatory anxiety—propranolol primarily addresses acute physical symptoms during the event itself. 5
Do not prescribe without screening for asthma or reactive airway disease—even a single dose can trigger life-threatening bronchospasm in susceptible patients. 1
Do not use in patients taking stimulants without careful cardiovascular assessment—the combination requires screening for cardiogenic shock and close monitoring. 1