Propranolol and Anxiety: An Off-Label Use of a Beta Blocker

What propranolol is

Propranolol is a nonselective beta blocker. MedlinePlus says it works by relaxing blood vessels and slowing the heart rate to improve blood flow and lower blood pressure. It comes as tablets, a liquid and long-acting capsules.

Current long-acting brands on DailyMed include Inderal LA and InnoPran XL, and generic forms are available. Each product has its own label, and the approved uses differ among them.

What it is approved for, and the off-label anxiety use

The FDA label for propranolol tablets lists high blood pressure, angina, rate control in atrial fibrillation, improving survival after a heart attack, migraine prevention (not treating a migraine that has started), essential tremor, hypertrophic subaortic stenosis and pheochromocytoma. The Inderal LA label lists fewer uses, and the InnoPran XL label lists high blood pressure only.

Anxiety is not on these labels, so its use for anxiety is off-label. MedlinePlus says propranolol is also sometimes used to treat anxiety and tells readers to talk with a doctor about the risks of using it that way.

A StatPearls chapter on NCBI Bookshelf says it is used off-label to reduce the physical symptoms of acute situational or performance anxiety, such as fast heartbeat, tremor and sweating. A 2020 review is more cautious: it says there is a lack of research support for propranolol in anxiety disorders, although it may still have a role in certain task-specific anxieties.

Those two statements fit together. Propranolol may calm the body's alarm signals in a specific moment, but that is different from treating an anxiety disorder over time. If anxiety is a daily or wide-ranging problem, ask about the range of online anxiety treatment options, and read our overview of anxiety medications.

How it is thought to work on anxiety symptoms

Beta blockers block adrenaline-type signals at beta receptors in the body. The label says this reduces how strongly the heart responds to that stimulation. StatPearls ties the off-label anxiety use to that effect on physical symptoms.

What taking it can be like

MedlinePlus lists dizziness or lightheadedness and tiredness among the side effects people may notice, so it is reasonable to ask your prescriber what to expect before an important event. Long-acting capsules are swallowed whole, and MedlinePlus says not to split, chew or crush them.

The way propranolol is used for an approved heart condition or migraine can be very different from an off-label use, so your prescriber sets the plan for your own situation. If you already take it for your heart or for migraine, your anxiety prescriber needs to know.

Side effects and warnings

Propranolol has no boxed warning on the tablet, Inderal LA or InnoPran XL labels, but the warnings section of the label is serious.

• Do not stop suddenly: the label reports worsening angina and, in some cases, heart attack after abrupt discontinuation, and MedlinePlus warns of serious heart problems. Any change should be planned with your prescriber, even if you take it for anxiety, since heart disease may be unrecognized.
• Who should not take it: the label lists cardiogenic shock, sinus bradycardia (slow heartbeat) and greater than first-degree heart block, bronchial asthma, and known hypersensitivity to propranolol.
• Lungs: people with lung conditions that narrow the airways generally should not receive beta blockers, because they can trigger an asthma attack.
• Heart failure and low blood sugar: it can worsen or lead to heart failure in some people. It can hide warning signs of low blood sugar and has been associated with low blood sugar, which matters for people with diabetes.
• Thyroid: it can hide signs of an overactive thyroid, and abrupt withdrawal can make symptoms worse.
• Side effects on the label include slow heartbeat, low blood pressure, cold or color-changing fingers from poor circulation, fatigue, vivid dreams, nausea, diarrhea and constipation. It also lists mental depression shown as insomnia, tiredness and weakness, so tell your prescriber about mood changes.
• Serious reactions: severe allergic reactions and serious skin reactions have been reported. Call 911 for trouble breathing or swelling of the face or throat.

Combinations that matter in mental health care

The label says blood levels of propranolol may rise with some other medicines, including the antidepressants fluoxetine, paroxetine, fluvoxamine and imipramine. It also describes interactions with heart medicines, including calcium channel blockers and antiarrhythmics. Share your full list, including anything from another prescriber. If you are pregnant, planning a pregnancy or breastfeeding, tell your prescriber.

Can propranolol be managed online in Pennsylvania and New York

The label does not limit it to clinic use, but a video visit cannot listen to your heart or lungs, so your prescriber may ask about your medical history, heart rate and blood pressure, or involve your primary care doctor. Whether it is an option for you is a decision for you and your prescriber. Ask us whether our psychiatrist can help, using our medication inquiry form.

A licensed psychiatrist on our team treats anxiety by secure video for people physically located in Pennsylvania or New York during each visit. See online psychiatry in New York and our medicines list. Our therapists do not prescribe, and they see clients in Pennsylvania, West Virginia, Arizona, Colorado and Florida, not New York. Ask us about fees and insurance.

If you are in crisis, call or text 988, or call 911. Locascio Wellness does not provide emergency services.