What is the role of Propranolol (beta blocker) in managing anxiety?

From the Guidelines

Propranolol is not the first-line treatment for anxiety, as SSRIs and SNRIs have shown higher efficacy and safety profiles in recent studies. When considering propranolol for anxiety management, it's essential to weigh the benefits and harms, particularly in the context of social anxiety disorder. According to the Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology clinical practice guideline for social anxiety disorder 1, SSRIs and SNRIs have demonstrated high treatment response rates and low dropout rates, making them preferred options.

Key Considerations for Propranolol Use

• Propranolol may still be considered for managing physical symptoms of anxiety, such as tremors, racing heart, and sweating, especially in performance anxiety and social anxiety where these symptoms are prominent.
• The typical dosage ranges from 10-40 mg taken 30-60 minutes before anxiety-provoking situations for situational anxiety, or 40-80 mg daily (often divided into multiple doses) for ongoing anxiety management.
• Propranolol works by blocking beta-adrenergic receptors, preventing adrenaline from increasing heart rate and blood pressure during anxiety responses.
• Side effects may include fatigue, dizziness, and cold extremities, and it should be avoided by people with asthma, certain heart conditions, or diabetes.

Evidence-Based Recommendations

• The most recent and highest quality study 1 supports the use of SSRIs and SNRIs as first-line treatments for social anxiety disorder due to their efficacy and safety profiles.
• While propranolol has been studied in the context of preventing PTSD 1, its efficacy in this area is not conclusively established, and it is not the primary indication for propranolol in anxiety management.
• Always consult with a healthcare provider before starting propranolol, as they can provide personalized dosing recommendations based on your specific situation and medical history, considering the latest evidence and guidelines.

From the Research

Efficacy of Propranolol for Anxiety

• The use of propranolol for anxiety disorders accompanied by physical symptoms, especially cardiovascular complaints, may be effective in some patients when combined with benzodiazepines or perhaps in some non-responders to conventional treatment 2.
• Propranolol may provide symptomatic relief in some patients with residual somatic complaints, such as palpitations and tachycardia, when combined with the patient's ongoing drug regimen 2.
• Benefits of beta-blockers, including propranolol, are limited to performance anxiety 3.
• Propranolol is one of the few medications successfully applied in the treatment of stage fright 4.

Comparison with Other Treatments

• There is no evidence to suggest that propranolol is more effective than benzodiazepines in the treatment of panic disorder with or without agoraphobia 5.
• No evidence was found for effects of propranolol on PTSD symptom severity through inhibition of memory reconsolidation 5.
• Beta-blockers, including propranolol, are not effective in the treatment of social phobia or panic disorder with/without agoraphobia compared to placebo or benzodiazepines 6.

Limitations and Future Research

• The quality of evidence for the efficacy of propranolol is insufficient to support its routine use in the treatment of any anxiety disorders 5.
• Many studies on the use of beta-blockers for anxiety have small sample sizes, missing data, and high or unclear risk of bias 6.
• There is a need for a large randomized controlled trial to provide definitive evidence of whether beta-blockers, including propranolol, are an effective and safe treatment for anxiety 6.