Beta-blockers for anxiety: WHICH beta-blocker to use?
World Health Organisation (WHO) defines anxiety disorders as a group of mental conditions characterised by a feeling of fear and anxiety (WHO, 2017). Some common forms of anxiety include generalised anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Pharmacological management of anxiety disorders involves the use of antidepressants, such as a selective serotonin reuptake inhibitor (SSRI) or a serotonin–noradrenaline reuptake inhibitor (SNRI). NICE guidelines on the management of generalised anxiety disorder and panic disorder in adults does not mention the use of beta-blockers, although it is known that beta-blockers may elevate the symptoms of anxiety. In this post, I will discuss the use of beta-blockers for anxiety, focusing on the use of propranolol, a common beta-blocker available in the UK.
What are beta-blockers?
β adrenergic receptor antagonists (commonly known as beta-blockers) are a group of drugs used in the management of:
- angina
- myocardial infarction (heart attacks)
- arrhythmias
- heart failure
- hypertension (not recommended as first-line treatment)
- migraine prevention and
- essential tremor
Beta-blockers can be divided into non-selective beta-blockers (for example, propranolol) and selective blockers (for example, bisoprolol, atenolol). Selectivity relates to the ability of beta-blockers to work in some regions of the body.
Beta-1 receptors are predominantly located in the heart, whereas beta-2 receptors are distributed throughout the body. Non-selective beta-blockers bind to both beta-1 and beta-2 receptors, whereas selective beta-blockers mainly to beta-1 receptors and are commonly known as ‘cardio-selective.’
Why beta blocker for anxiety?
Non-selective beta-blockers are used for anxiety management. Beta-blockers can be used in some patients for specific symptoms anxiety such as:
- tremor
- shaking
- palpitations and
- fast heart rate
Beta-blockers do not help with psychological symptoms of anxiety, such as feeling worried, fearful, or tension (NICE, 2020). Beta-blockers block the actions of norepinephrine and epinephrine (adrenaline). Both hormones are responsible for the ‘fight or flight’ response characterised by an increase in the heart rate and tremor also associated with symptoms of anxiety.
Similarly to anxiety disorders, beta-blockers can be used to control symptoms of performance anxiety, such as public speaking. People who experience stage fright may comfort similar to panic disorder symptoms such as tremors, increased heartbeats/palpitations, and sweating affecting their performance (Bourgeois, 1991).
By blocking physiological signs of anxiety, beta-blockers create a positive feedback loop, and as a result, patients become less conscious of being anxious (ibid).
Why is propranolol used for anxiety?
Propranolol is a non-selective beta-blocker and the only beta-blocker used (licensed) in the management of anxiety in the UK. Propranolol is a prescription-only medication, which means it can only be obtained on a prescription written by a qualified prescriber.
In relation to anxiety, propranolol is licensed in the management of:
- Anxiety tachycardia (fast heartbeat due to anxiety)
- Anxiety with symptoms such as palpitation, sweating, and tremor
Propranolol for the anxiety: dosage
The recommended daily dose of propranolol in the management of anxiety is 40mg once daily.
If necessary, this dose can be increased up to 40mg 3 times a day.
Propranolol is available as 10mg, 40mg, and 80mg tablets, as well as 80mg and 160mg, sustained-release capsules.
Propranolol sustained-release (also called modified release) is taken daily as compared to standard tablets, which can be taken up to three times a day. When sustained-release capsules are used for the management of situational and generalised anxiety, a daily dose of 80mg of propranolol should be adequate to provide short-term relief of acute situational anxiety (EMC, 2020). Long term management of generalised anxiety can be managed with the same dose, or if necessary, the dose can be increased to 160mg of sustained-release propranolol.
For dosage instructions, follow the directions of the prescriber.
Propranolol for anxiety: possible side effects
The use of beta-blockers, such as propranolol, is associated with several possible side effects. Common side effects include:
- Sleep disturbances, nightmares
- Slow heart rate
- Cold extremities (fingers or toes)
- Fatigue, feeling tired.
- Nausea (feeling sick)
- Dizziness
- Erectile dysfunction
Some side effects, such as dizziness, may go away after a few days once the body gets used to the treatment. For less common side effects, please refer to propranolol’s product information leaflet.
Effectiveness of beta-blockers for anxiety
Systemic review and meta-analysis (review of all available evidence) do not give definite conclusions in favour or against the use of propranolol in the treatment of anxiety disorders. The main reason is the lack of well-designed clinical trials to show the efficacy of propanol in the management of anxiety (Steenen, et al 2015). Despite the lack of strong evidence, beta-blockers can provide for symptomatic relief of anxiety, including performance anxiety.
Beta-blockers for anxiety: conclusion
Evidence-based recommendations on the management of anxiety recommend a selective serotonin reuptake inhibitor (SSRI) as first-line drug treatment of this condition. In the UK, the only beta-blocker recommended for the management of anxiety is propranolol. Patients experiencing physical symptoms of anxiety, such as rapid heart rate and tremor, may benefit from the treatment with a beta-blocker.
References:
Bourgeois James A. (1991). The Management of Performance Anxiety with Beta-Adrenergic Blocking Agents. Available at: https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1284&context=jeffjpsychiatry Accessed on 21/04/2020
EMC (2020). SmPC: Bet- Prograne 160mg Sustained Release Capsules. Available at: https://www.medicines.org.uk/emc/product/11217/smpc Accessed on 21/04/2020
NICE (2020). Hypnotics and anxiolytics. Available at: https://bnf.nice.org.uk/treatment-summary/hypnotics-and-anxiolytics.html Accessed on 20/04/2020
WHO (2017). Depression and Other Common Mental Disorders. Available at: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf Accessed on 19/04/2020
