What is the recommended starting and maximum dose of propranolol for performance anxiety in an adult without contraindications such as asthma, severe bradycardia, heart block, uncontrolled heart failure, or hypotension?

Propranolol Dosing for Performance Anxiety

For performance anxiety in adults without contraindications, take propranolol 10–20 mg orally 30–60 minutes before the anxiety-provoking event, with a maximum single dose of 40 mg. 1

Patient Selection

Best candidates are individuals facing infrequent, predictable performance situations (public speaking, musical performances, presentations) whose primary symptoms are physical manifestations of autonomic hyperactivity—tremor, palpitations, tachycardia, and sweating—rather than psychological worry or rumination. 1

Poor candidates include those with chronic daily anxiety or predominantly cognitive symptoms; these patients require SSRIs, SNRIs, or cognitive-behavioral therapy instead. 1

Dosing Protocol

Single-Dose Situational Use (Preferred)

• Starting dose: 10–20 mg immediate-release propranolol taken 30–60 minutes before the performance or event 1
• Maximum single dose: 40 mg 1
• Timing: Administer 30–60 minutes prior to the anticipated trigger to allow peak effect during the event 1

Chronic Daily Dosing (Only if Frequent Events)

If performance situations occur frequently enough to warrant daily therapy:

• Initial dose: 40 mg twice daily (80 mg total daily) of immediate-release propranolol 1
• Titration: Increase to 80–160 mg daily in 2 divided doses based on response 1, 2
• Alternative: Propranolol LA (long-acting) 80 mg once daily, titrated to 120–160 mg once daily 1
• Maximum: 640 mg daily if needed, though this is rarely required for anxiety 1

Important: Chronic daily dosing is explicitly not recommended by international guidelines for situational anxiety; propranolol should be reserved for as-needed use in this context. 1

Mandatory Pre-Treatment Screening

Before prescribing propranolol, exclude these absolute contraindications:

• Cardiac: Second- or third-degree heart block, decompensated heart failure, severe left ventricular dysfunction, sinus node dysfunction without pacemaker, cardiogenic shock, systolic blood pressure <90 mmHg 1, 2
• Respiratory: Asthma or obstructive airway disease (propranolol's non-selective β₂-blockade can precipitate life-threatening bronchospasm) 1, 2
• Metabolic: Recent or ongoing hypoglycemic episodes, especially in diabetic patients 1

Baseline assessment should include:

• Heart rate and blood pressure measurement 1
• Cardiovascular examination with auscultation 1
• History screening for bronchospasm, diabetes, and medications affecting cardiac conduction 1

Administration Guidelines

• Take with food to reduce hypoglycemia risk, particularly if the patient has not eaten recently 1
• Hold doses during times of diminished oral intake or vomiting 1
• No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic 1

Critical Safety Warnings

Hypoglycemia Masking

Propranolol masks adrenergic warning signs of hypoglycemia (tremor, rapid heartbeat, sweating) in diabetic patients or those prone to low blood sugar. Patients must rely on non-adrenergic cues such as hunger, confusion, or sweating to detect hypoglycemia and should monitor blood glucose more frequently. 1

Discontinuation

Never abruptly discontinue propranolol after chronic use, as this can precipitate rebound hypertension, tachycardia, or angina. Taper gradually over 1–3 weeks when stopping. 1, 2

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

Monitoring for Adverse Effects

Watch for signs of excessive β-blockade:

• Cardiovascular: Dizziness, lightheadedness, marked fatigue, heart rate <50 bpm, systolic blood pressure <90 mmHg 1
• Respiratory: New or worsening shortness of breath or wheezing 1
• Metabolic: Symptoms of hypoglycemia in susceptible patients 1

Evidence Strength

The recommendation for propranolol in performance anxiety is supported by strong guideline consensus from the American College of Cardiology, American Heart Association, and Japanese Society of Anxiety and Related Disorders. 1 The Japanese guidelines explicitly endorse propranolol for performance-related anxiety with prominent somatic symptoms while deprecating its use for generalized social anxiety disorder. 1

Common Pitfalls

• Do not prescribe for chronic daily anxiety: Propranolol is ineffective for generalized anxiety disorder and should not replace first-line SSRIs/SNRIs in that context 1
• Do not use in patients with even mild asthma: The non-selective β-blockade can trigger bronchospasm; cardioselective agents (metoprolol) are also risky in reactive airway disease 1
• Do not exceed 40 mg as a single situational dose: Higher single doses increase adverse effects without additional benefit 1