Can you give a concise step‑by‑step protocol for a nurse practitioner to prescribe propranolol (a non‑selective β‑blocker) for performance anxiety during public speaking, including screening for contraindications, baseline vitals, dosing schedule, side‑effect counseling, alternative agents, and follow‑up?

Propranolol Protocol for Performance Anxiety in Public Speaking

Step 1: Screen for Absolute Contraindications

Before prescribing propranolol, you must exclude the following absolute contraindications:

• Obstructive airway disease (asthma, COPD, or any active bronchospasm) – non-selective β-blockade can precipitate life-threatening bronchospasm 1
• Second- or third-degree AV block without a functioning pacemaker 1
• Decompensated heart failure or cardiogenic shock 1
• Sinus bradycardia (<50 bpm) or sinus node dysfunction without a pacemaker 1
• Severe hypotension (systolic BP <90 mmHg) 1
• Recent or ongoing hypoglycemic episodes 1

Step 2: Baseline Assessment

Obtain the following before the first dose:

• Heart rate and blood pressure (sitting) – document baseline values 1
• Cardiovascular examination with auscultation to detect murmurs or signs of heart failure 1
• Screen for history of bronchospasm, diabetes, and concurrent medications that affect cardiac conduction (digoxin, diltiazem, verapamil, amiodarone) 1
• No routine ECG, echocardiogram, or laboratory work is required in otherwise healthy adults 1

Step 3: Dosing Schedule

For situational performance anxiety (e.g., public speaking):

• Prescribe propranolol immediate-release 10–20 mg as a single dose taken 30–60 minutes before the anxiety-provoking event 1
• Maximum single situational dose: 40 mg 1
• This is NOT for chronic daily anxiety – propranolol is ineffective for generalized anxiety and should not be used continuously for this indication 1, 2

If the patient requires frequent dosing (multiple events per week):

• Consider propranolol immediate-release 40 mg twice daily (total 80 mg/day) as a baseline regimen, with the option to add a supplemental 10–20 mg dose before specific events 1
• Titrate to 80–160 mg/day in divided doses if needed for blood pressure control or more frequent performance situations 1

Step 4: Side-Effect Counseling

Warn the patient about the following:

• Hypotension and dizziness – especially if standing quickly; advise caution when driving or operating machinery after the first dose 1
• Bradycardia – may cause fatigue or lightheadedness if heart rate drops below 50 bpm 1
• Masking of hypoglycemia symptoms – in diabetic patients, propranolol blunts tremor and tachycardia that signal low blood sugar; instruct patients to monitor glucose more frequently and rely on non-adrenergic cues (hunger, confusion, sweating) 1
• Cold extremities – due to peripheral vasoconstriction from β2-blockade 1
• Do NOT abruptly discontinue after regular use – taper gradually over 1–3 weeks to prevent rebound hypertension, tachycardia, or angina 1

Instruct the patient to hold the dose and contact you if they experience:

• Wheezing or shortness of breath 1
• Heart rate <50 bpm with dizziness or syncope 1
• Systolic BP <90 mmHg with symptoms 1

Step 5: Drug Interactions

Avoid or use extreme caution with:

• Non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) – markedly increases risk of severe bradycardia and heart block 1
• Other rate-lowering agents (digoxin, amiodarone, ivabradine) – additive bradycardic effects 1
• Dofetilide – propranolol is contraindicated with this antiarrhythmic 1

Step 6: Alternative Agents

If propranolol is contraindicated or poorly tolerated:

• Cardioselective β1-blockers (metoprolol tartrate 25 mg or atenolol 25 mg) may be considered in patients with mild reactive airway disease, though they still carry bronchospasm risk and are less effective for peripheral tremor 1
• SSRIs/SNRIs (escitalopram, sertraline, venlafaxine) are first-line for chronic generalized anxiety and should be used instead of propranolol for daily symptoms 1
• Cognitive-behavioral therapy is the most effective non-pharmacologic intervention for performance anxiety 1

Step 7: Follow-Up

For stable patients on low-dose situational propranolol:

• No routine follow-up visits or vital sign monitoring are required if the patient remains asymptomatic 1
• Schedule a visit only if the patient develops symptoms of excessive β-blockade (dizziness, fatigue, bradycardia) or if dosing adjustments are needed 1

For patients on chronic daily dosing:

• Reassess heart rate and blood pressure at 1–2 weeks after initiation or dose increase 1
• Target resting heart rate 50–80 bpm for most indications 3

Common Pitfalls to Avoid

• Do NOT prescribe propranolol for chronic daily anxiety – it is ineffective for generalized anxiety disorder and lacks evidence for long-term use 1, 2
• Do NOT use propranolol in patients with even mild asthma – non-selective β-blockade can be fatal in this population 1
• Do NOT combine propranolol with diltiazem or verapamil – this combination causes severe bradycardia and heart block 1
• Do NOT abruptly stop propranolol after regular use – taper over 1–3 weeks to prevent rebound cardiovascular events 1