Is Propranolol Off-Label in Australia for Public Speaking Anxiety?
Yes, propranolol is off-label in Australia for public speaking anxiety—it is not formally approved by the TGA (Therapeutic Goods Administration) for this indication, but it is widely used and supported by strong international guideline consensus for performance-related situational anxiety. 1, 2, 3
Regulatory Status and Clinical Endorsement
Propranolol's only approved indications in most jurisdictions (including Australia) are cardiovascular conditions such as hypertension, arrhythmias, and angina; anxiety disorders—including performance anxiety—are not listed on the product label. 1
Despite the off-label status, the American College of Cardiology, American Heart Association, and Japanese Society of Anxiety and Related Disorders all endorse propranolol for situational performance anxiety when somatic symptoms (tremor, palpitations, tachycardia, sweating) predominate. 1, 2, 3
The Japanese Society of Anxiety and Related Disorders explicitly deprecates propranolol for generalized social anxiety disorder but strongly endorses it for performance-related anxiety such as public speaking, where physical autonomic hyperactivity is the primary manifestation. 1, 2
Evidence Base for Performance Anxiety
Multiple placebo-controlled studies demonstrate that propranolol (20–40 mg taken 30–60 minutes before an event) significantly reduces rated anxiety in non-verbal behavior, speech quality, and self-reported anxiety during public speaking tasks. 4, 5
A 1983 British Journal of Psychiatry study showed that propranolol 40 mg clearly reduced observer-rated anxiety in anxious speakers and lowered pulse rate in both anxious and non-anxious subjects, confirming both peripheral and central adrenergic blockade. 5
A 2022 review in the International Journal of Molecular Sciences concluded that propranolol is "one of the very few medications successfully applied in the treatment of stage fright," with efficacy attributed to its ability to cross the blood-brain barrier and block both peripheral and central β-receptors. 6
Recommended Dosing for Public Speaking Anxiety
Single-dose regimen (preferred for infrequent events): Take 10–20 mg immediate-release propranolol 30–60 minutes before the anxiety-provoking event; the maximum single situational dose should not exceed 40 mg. 1, 3
Chronic daily dosing (for frequent performance situations): Initiate immediate-release propranolol 40 mg twice daily (total 80 mg/day) and titrate to 80–160 mg/day in two divided doses, or use long-acting propranolol 80 mg once daily, titrating to 120–160 mg once daily. 1
Hybrid approach: Maintain a baseline antihypertensive dose (e.g., 80 mg/day) and add a supplemental 10–20 mg dose 30–60 minutes before a known event; the maximum single situational dose remains 40 mg. 1
Mandatory Pre-Treatment Screening
Absolute contraindications that must be excluded before prescribing propranolol include: 1, 3
- Asthma or obstructive airway disease (risk of life-threatening bronchospasm due to non-selective β₂-blockade)
- Second- or third-degree atrioventricular block without a pacemaker
- Decompensated heart failure or severe left-ventricular dysfunction
- Cardiogenic shock
- Sinus node dysfunction or sinus bradycardia without a pacemaker
- Severe hypotension (systolic BP < 90 mm Hg)
Baseline assessment should include heart rate and blood pressure measurement, cardiovascular examination with auscultation, and screening for history of bronchospasm, diabetes, and concurrent medications that affect cardiac conduction. 1, 3
Routine blood work (CBC, renal, liver, thyroid panels), ECG, or echocardiogram are not required in otherwise healthy adults without cardiac concerns. 1, 3
Critical Safety Warnings
Drug Interactions
- Avoid routine co-administration with non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) because the combination markedly increases the risk of severe bradycardia and heart block. 1
Hypoglycemia Masking
- Propranolol can mask adrenergic warning signs of hypoglycemia (tremor, tachycardia, palpitations) in diabetic patients; counsel these patients to increase blood glucose monitoring frequency and rely on non-adrenergic cues (hunger, confusion, sweating). 1, 3
Discontinuation
Never abruptly discontinue propranolol after chronic use—taper gradually over 1–3 weeks to prevent rebound hypertension, tachycardia, or angina. 1, 3
For temporary interruption during acute illness (e.g., vomiting, reduced oral intake), propranolol may be held without a taper and then re-started at a lower dose once oral intake normalizes. 1
Common Pitfalls and How to Avoid Them
Pitfall 1: Using Propranolol for Chronic Daily Anxiety
Propranolol is not suitable for chronic anxiety treatment; SSRIs (escitalopram, sertraline) or SNRIs (venlafaxine) are first-line for generalized anxiety disorder and chronic social anxiety. 1, 2
The Japanese Society of Anxiety and Related Disorders explicitly deprecates propranolol for generalized social anxiety disorder based on negative evidence. 1
Pitfall 2: Prescribing to Patients with Reactive Airway Disease
- Even mild wheezing or COPD is an absolute contraindication to propranolol; if β-blockade is needed, use a cardioselective β₁-blocker (metoprolol, atenolol) at reduced doses, recognizing that these agents are less effective for tremor and anxiety. 1
Pitfall 3: Failing to Advise a Trial Dose
- Patients should take a trial dose before an important event to assess individual response and tolerability, as some individuals experience excessive fatigue or dizziness. 2
Monitoring Requirements
For stable patients on low-dose situational propranolol: Routine follow-up visits and vital sign monitoring between appointments are not required if the patient remains asymptomatic. 1
For patients on chronic daily dosing: Monitor for hypotension, bradycardia (heart rate < 50 bpm), dizziness, marked fatigue, and new or worsening shortness of breath/wheezing. 1
Alternative Approaches
For chronic performance anxiety: Cognitive-behavioral therapy (CBT) shows superior long-term outcomes compared with propranolol and should be considered first-line for frequent or chronic performance anxiety. 2, 7
A 1991 American Journal of Psychiatry study demonstrated that CBT resulted in statistically significant reductions in subjective anxiety, improved quality of musical performance, and improved performance confidence in musicians with performance anxiety, whereas buspirone was ineffective. 7
For patients with contraindications to propranolol: Cardioselective β₁-blockers (metoprolol 25–50 mg, atenolol 25–50 mg) may be used, but evidence for anxiety efficacy is weaker and tremor control is inferior. 1
Summary of Evidence Strength
The recommendation to use propranolol for performance-related anxiety is supported by strong guideline consensus from the American College of Cardiology, American Heart Association, and Japanese Society of Anxiety and Related Disorders, reflecting Class I evidence for the dosing ranges in cardiovascular contexts that inform its off-label anxiety use. 1, 2, 3
Multiple placebo-controlled trials from the 1980s–1990s and a 2022 systematic review confirm efficacy for situational anxiety with prominent somatic symptoms. 4, 6, 5