What is the recommended propranolol dosing regimen for a patient with performance‑type situational anxiety who has no contraindications to beta‑blockade?

Propranolol Dosing for Situational Anxiety

For performance-type situational anxiety with prominent somatic symptoms (tremor, palpitations, sweating), administer propranolol immediate-release 10–40 mg as a single dose taken 30–60 minutes before the anxiety-provoking event. 1

Patient Selection

Propranolol is most effective for patients experiencing physical manifestations of autonomic hyperactivity rather than predominantly psychological symptoms of worry or rumination. 1 The ideal candidate presents with:

• Tremor, palpitations, tachycardia, or sweating during specific performance situations 2
• Mild to moderate situational anxiety limited to predictable triggers 2
• No contraindications to beta-blockade 1

Dosing Regimen

Single-Event Dosing (Primary Recommendation)

Start with 10–20 mg immediate-release propranolol taken 30–60 minutes before the anticipated stressor. 1 This lower range is appropriate for most patients without prior beta-blocker exposure. If inadequate symptom control occurs with initial dosing, the dose may be increased to a maximum of 40 mg for subsequent events. 1

Chronic Daily Dosing (For Frequent Episodes)

If performance situations occur regularly (e.g., daily public speaking), consider initiating propranolol 40 mg twice daily (80 mg total daily) and titrating to 80–160 mg daily in divided doses based on response. 1 Long-acting formulations may be dosed 80 mg once daily, titrated to 120–160 mg once daily. 1

Hybrid Approach

For patients requiring baseline blood pressure control who also experience occasional performance anxiety, maintain a standard antihypertensive dose and add a supplemental 10–20 mg immediate-release dose 30–60 minutes before known triggers, not exceeding 40 mg as a single situational dose. 1

Mandatory Pre-Treatment Screening

Before prescribing propranolol, screen for absolute contraindications including:

• Second- or third-degree atrioventricular block (without pacemaker) 1, 2
• Decompensated heart failure or severe left ventricular dysfunction 1, 2
• Asthma or obstructive airway disease—this is a life-threatening contraindication due to risk of bronchospasm 1, 2
• Cardiogenic shock 1, 2
• Sinus node dysfunction or sinus bradycardia without pacemaker 1, 2
• Severe hypotension 1

Obtain baseline heart rate and blood pressure measurement before the first dose. 1 Perform cardiovascular examination with auscultation and screen for history of bronchospasm, diabetes, and medications affecting cardiac conduction. 1

Critical Safety Warnings

Hypoglycemia Masking

In diabetic patients or those with history of hypoglycemic episodes, propranolol masks adrenergic warning signs of low blood glucose (tremor, tachycardia). 1, 2 These patients must monitor glucose more frequently and rely on non-adrenergic cues such as hunger, confusion, or sweating. 1 Propranolol should be taken with food to reduce hypoglycemia risk. 1

Drug Interactions

Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to markedly increased risk of severe bradycardia and heart block. 1, 2

Discontinuation

After regular propranolol use, abrupt discontinuation may precipitate rebound hypertension, tachycardia, or angina; taper gradually over 1–3 weeks when stopping chronic therapy. 1 For occasional as-needed use, tapering is not required. 1

Monitoring for As-Needed Use

For healthy patients using propranolol occasionally, no routine monitoring between appointments is required. 1, 2 However, instruct patients to:

• Check pulse before each dose and hold if heart rate is below 60 beats per minute 2
• Watch for signs of excessive beta-blockade: dizziness, marked fatigue, light-headedness, heart rate below 50 bpm, systolic blood pressure below 90 mm Hg, or new shortness of breath/wheezing 1

Evidence Limitations and Clinical Context

The most recent systematic review and meta-analysis (2025) found no evidence for beneficial effect of beta-blockers in social phobia or panic disorder when compared to placebo or benzodiazepines. 3 However, this analysis focused on chronic anxiety disorders rather than acute performance-type situational anxiety. Older studies from the 1970s–1990s demonstrated efficacy specifically for performance anxiety and somatic symptoms at doses of 20–40 mg. 4, 5, 6

The Japanese Society of Anxiety and Related Disorders explicitly states that propranolol is not suitable for chronic generalized social anxiety disorder but is effective for performance anxiety with prominent somatic symptoms. 1 This distinction is critical: propranolol addresses peripheral autonomic manifestations, not core psychological anxiety symptoms.

Common Pitfalls

• Do not prescribe propranolol for patients with predominantly cognitive/psychological anxiety symptoms (worry, fear of negative evaluation) without somatic features—it will be ineffective. 1
• Never use in patients with asthma or reactive airway disease—even cardioselective beta-blockers retain bronchospasm risk. 1, 2
• Do not combine with diltiazem or verapamil—this combination causes profound bradycardia. 1, 2
• Avoid in diabetic patients unless absolutely necessary—if prescribed, counsel extensively about hypoglycemia masking and increase glucose monitoring frequency. 1, 2