Is propranolol appropriate for short‑term performance anxiety, what dosing regimen should be used, and what contraindications or precautions must I consider?

Propranolol for Performance Anxiety

Propranolol 20–40 mg taken 1 hour before a performance event is the appropriate treatment for short-term situational anxiety with prominent physical symptoms (tremor, palpitations, sweating), but it is explicitly not recommended for chronic or generalized anxiety disorders. 1, 2

When Propranolol IS Appropriate

• Situational performance anxiety only: Use propranolol for infrequent, predictable anxiety-provoking events such as public speaking, musical performances, or test-taking when physical autonomic symptoms (rapid heartbeat, tremor, sweating) are the primary concern. 1, 2
• The American College of Cardiology and international guidelines endorse propranolol specifically for acute situational use, not chronic daily therapy. 1, 2
• Propranolol works by blocking peripheral β-adrenergic receptors, thereby reducing the physical manifestations of adrenaline without directly affecting the psychological components of anxiety. 1

Dosing Regimen

• Single-dose strategy: Administer 20–40 mg of immediate-release propranolol 1 hour before the anxiety-provoking event. 1, 2
• Critical practice point: Advise the patient to take a trial dose before an important event to assess individual response and tolerability, as some patients may experience excessive fatigue or dizziness. 1, 2
• For patients who require propranolol more than once weekly but still for discrete events, the same single-dose approach applies each time; do not transition to daily dosing unless treating a separate cardiovascular indication. 1

Absolute Contraindications – Screen Before Prescribing

You must exclude the following before writing a prescription:

• Asthma or chronic obstructive pulmonary disease: Non-selective β-blockade can precipitate life-threatening bronchospasm. 1, 3, 2
• Second- or third-degree atrioventricular block or sinus node dysfunction (without a pacemaker): Propranolol will worsen conduction abnormalities. 1, 3, 2
• Decompensated heart failure or cardiogenic shock: β-blockade further reduces cardiac output. 1, 3, 2
• Severe bradycardia (resting heart rate <50 bpm) or severe hypotension (systolic BP <90 mm Hg). 1, 3
• Known hypersensitivity to propranolol. 2

Important Precautions

• Diabetes: Propranolol masks adrenergic warning signs of hypoglycemia (tremor, tachycardia); counsel diabetic patients to monitor blood glucose more frequently and rely on non-adrenergic cues such as sweating, hunger, or confusion. 1, 3, 2
• Drug interactions: Avoid co-administration with non-dihydropyridine calcium-channel blockers (diltiazem, verapamil), as this combination markedly increases the risk of severe bradycardia and heart block. 1, 3
• Abrupt discontinuation: If a patient has been taking propranolol regularly (not just situationally), do not stop it suddenly; taper over 1–3 weeks to prevent rebound hypertension, tachycardia, or angina. 1, 3, 2

Baseline Assessment

Before the first dose, obtain:

• Resting heart rate and blood pressure to confirm the patient is not bradycardic or hypotensive. 1, 3
• History of bronchospasm, cardiac disease, and diabetes. 1, 3
• Current medication list to identify potential drug interactions (especially calcium-channel blockers, other β-blockers, or antiarrhythmic agents). 1, 3

Routine ECG, echocardiogram, or laboratory work is not required in otherwise healthy adults without cardiac symptoms or risk factors. 1, 3

Monitoring After Initiation

• No routine follow-up visits or vital-sign checks are necessary for stable patients using propranolol only for occasional situational anxiety. 1, 3
• Instruct the patient to report dizziness, marked fatigue, light-headedness, new shortness of breath, or wheezing, as these may indicate excessive β-blockade or bronchospasm. 1, 3

When Propranolol Is NOT Appropriate

• Chronic or generalized anxiety disorder: Canadian and international guidelines explicitly deprecate propranolol for chronic social anxiety or generalized anxiety; SSRIs (escitalopram, sertraline) or SNRIs (venlafaxine) are first-line pharmacotherapy. 1, 2
• Panic disorder: Meta-analysis of randomized controlled trials found no statistically significant benefit of propranolol over placebo for panic disorder; benzodiazepines or SSRIs/SNRIs are preferred. 4
• Post-traumatic stress disorder: Evidence does not support routine use of propranolol for PTSD symptom reduction. 4
• Frequent performance anxiety: If the patient faces anxiety-provoking situations multiple times per week or has pervasive worry, cognitive-behavioral therapy (CBT) is first-line, with SSRIs/SNRIs as pharmacotherapy if needed—not daily propranolol. 1, 2

Common Pitfalls and How to Avoid Them

• Prescribing for the wrong indication: Do not use propranolol for chronic daily anxiety; it is effective only for acute situational use with somatic symptoms. 1, 2, 4
• Failing to screen for asthma: Even mild reactive airway disease is a contraindication; always ask about wheezing or inhaler use. 1, 3, 2
• Ignoring diabetes: Patients with diabetes require explicit counseling about hypoglycemia masking and more frequent glucose monitoring. 1, 3
• Combining with calcium-channel blockers: This combination is dangerous; review the medication list carefully. 1, 3
• Not advising a trial dose: Individual responses vary; a test dose before a high-stakes event prevents unpleasant surprises. 1, 2

Alternative Agents When Propranolol Is Contraindicated

• Cardioselective β₁-blockers (metoprolol 25–50 mg, atenolol 25–50 mg) may be used with extreme caution in patients with mild reactive airway disease, but they are less effective for tremor and performance anxiety and still carry bronchospasm risk. 1, 3
• For patients with any degree of asthma or COPD, do not use any β-blocker; consider CBT or SSRIs/SNRIs instead. 1, 3, 2

Evidence Strength

The recommendation for propranolol in situational 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, 2 However, systematic review and meta-analysis demonstrate insufficient evidence to support propranolol for chronic anxiety disorders, panic disorder, or PTSD. 4 Older studies from the 1970s–1990s suggested benefit in somatic anxiety symptoms 5, 6, 7, 8, but contemporary guidelines prioritize SSRIs/SNRIs for any chronic anxiety condition. 1, 2