Propranolol (Inderal)

What it treats

Propranolol is a beta blocker. It is approved by the U.S. Food and Drug Administration for heart conditions, high blood pressure, migraine prevention, and tremor. In psychiatry it is used off-label, meaning for a purpose the label doesn't formally list even though evidence and practice support it, for the physical symptoms of anxiety. Its main psychiatric use is for situational or performance anxiety, such as stage fright or public speaking.

It is worth being clear that the anxiety use is off-label. Propranolol is not a treatment for an anxiety disorder broadly. For ongoing anxiety, SSRIs, SNRIs, and therapy are the mainstays. Propranolol fills a narrower role: easing the physical side of a stressful, time-limited situation.

How it works

Propranolol blocks the action of adrenaline on the body's beta receptors, which are sites that adrenaline acts on to speed the heart and prime the body for action. It does not act on the brain's anxiety circuits the way an SSRI or a benzodiazepine does.

Instead, it blunts the physical symptoms of the fight-or-flight response: the racing heart, the trembling hands, the shaky voice. In other words, it treats the body's anxiety symptoms rather than the mental experience of worry itself. For someone whose main problem before a presentation is a pounding heart and unsteady hands, that can be exactly the right tool. For the worry itself, it does less.

What to expect

Taken before a stressful event, propranolol works within about an hour. The physical symptoms it targets, like a fast heartbeat and trembling, tend to be noticeably calmer.

For performance or situational anxiety, propranolol is often used as needed rather than every day. Many people take it only on the days they expect a triggering situation. How and when to use it is something a prescriber sets based on the situation.

Common side effects

Side effects are usually mild, especially with occasional use. The common ones include:

• Tiredness.
• Cold hands and feet.
• Dizziness or lightheadedness, from a lowered heart rate and blood pressure.
• Sometimes vivid dreams.

These effects are more noticeable with regular daily use than with occasional as-needed use. If a side effect is bothersome, that's a conversation to have with the prescriber.

Serious side effects and warnings

Propranolol is generally well tolerated, and serious problems are uncommon. A few points are worth knowing.

• It lowers heart rate and blood pressure. For that reason it is used carefully in people with certain heart conditions or a very low heart rate.
• It can narrow the airways. Because of this, propranolol is generally avoided in people with asthma.
• It can mask warning signs of low blood sugar. Some of the early signs of low blood sugar, such as a fast heartbeat, can be blunted by propranolol, which matters for people with diabetes.
• Regular use should not be stopped abruptly. If propranolol is taken regularly for a heart condition, stopping it suddenly can be a problem, so it is tapered. Occasional as-needed use for performance anxiety is a different situation.

Propranolol is not a controlled substance and does not cause dependence.

Sexual side effects

Beta blockers can occasionally contribute to erectile difficulties. This is more likely with regular daily use than with occasional, as-needed use for performance anxiety. If you do notice a change, it is worth raising with your prescriber, since other factors, including anxiety itself, can play a part.

Weight, appetite, and sleep

Propranolol is not a major cause of weight change. It does not typically affect appetite the way some other medications can.

It can cause vivid dreams in some people, more so with regular use. If sleep is disrupted, a prescriber can review the dose and timing.

Starting and dosing basics

This section is general background, not a dosing instruction for any individual. The right dose and how it is used are decisions for a prescriber.

Propranolol comes as tablets and as capsules. For performance anxiety, a low dose is taken before the event. The prescriber sets the dose and decides how it should be used, based on the situation and how a person responds.

Missed doses and interactions

For as-needed use before a stressful event, follow the prescriber's guidance, since occasional use does not involve a fixed daily schedule.

Interactions are worth checking. Other medications that lower blood pressure or heart rate can add to propranolol's effect. Caution is also needed alongside asthma medications, since propranolol can work against them. Give every prescriber and pharmacist a full list of your medications and supplements, including over-the-counter ones, so these combinations can be checked.

Stopping and tapering

Occasional as-needed use of propranolol for performance anxiety is straightforward to stop. There is no dependence and no need for a taper when it has only been used now and then.

If propranolol is taken regularly, for example for a heart condition, the situation is different. Regular use should not be stopped abruptly, and coming off it should be planned with a prescriber.

Pregnancy and breastfeeding

This is an area where individual circumstances matter and the decision belongs with a clinician. Anyone who is pregnant, planning a pregnancy, or breastfeeding should discuss propranolol with their prescriber so the specific risks and benefits can be weighed for their situation.

Cost and generic availability

Propranolol has been available as a generic for many years and is very inexpensive. The brand name Inderal and generic propranolol contain the same active medication and work the same way. Most insurance plans cover it, and for people paying out of pocket, generic propranolol is low-cost.

Common questions

Does propranolol treat anxiety, or just the physical symptoms? It treats the physical symptoms, like a racing heart and trembling hands, rather than the mental experience of worry. It does not act on the brain's anxiety circuits the way an SSRI or a benzodiazepine does.

Is propranolol addictive? No. It is not a controlled substance and does not cause dependence or cravings.

Can I take it as needed before a presentation? For performance or situational anxiety, propranolol is often used exactly that way, as needed before the event rather than every day. A prescriber sets how and when to use it.

Who should not take it? Propranolol is generally avoided in people with asthma, and it is used carefully in people with certain heart conditions, a very low heart rate, or diabetes. A prescriber will review your health history before recommending it.

How fast does it work? Taken before a stressful event, propranolol works within about an hour.

Questions to ask your prescriber

• What are we hoping this treats, and how will we know it's working?
• How and when should I take it, and how often?
• Which medications and substances should I avoid while on it?
• Are there any health conditions I have that make this a poor fit?
• If I end up needing it more often, what would we consider instead?

Sources

• U.S. Food and Drug Administration. Propranolol (Inderal) prescribing information.
• MedlinePlus, U.S. National Library of Medicine. Propranolol.
• National Institute of Mental Health. Mental health medications.