Propranolol, from the prescribing side

TL;DR: Propranolol is a 60-year-old heart pill that blocks adrenaline from reaching your heart, lungs, and muscles. Taken about an hour before a big moment, it stops the pounding chest, the shaking hands, and the wobble in your voice. It does not touch the fear itself, and it is not a calming pill. The usual dose is 10mg to 20mg, taken only on the days you need it. Take your very first one at home on a quiet day so you learn how it feels. Do not take it if you have asthma, COPD, a slow heartbeat, heart block, heart failure, or low blood pressure. Tell your doctor if you use insulin, take a migraine pill, or compete in a tested sport, because each of those changes the answer. This use is off-label, meaning the FDA approved the drug for other things. The tablets themselves are cheap generics. Tell Dr. Ash what happens to you and he will tell you whether this is your problem.

Most of what is written about propranolol and stage fright was written to sell it. This page is written from the other side of the desk, by the physician who has to decide whether to put your name on the prescription, and it covers the parts that decision turns on.

If you are here because your body overrides your preparation, the companion page on performance anxiety starts with the problem instead of the molecule. This one starts with the molecule.

What is propranolol?

Propranolol is a non-selective beta-adrenergic blocking agent, the first beta-blocker to reach clinical use, introduced in the 1960s and on the World Health Organization's list of essential medicines ever since. The FDA has approved it for hypertension, angina, certain arrhythmias, essential tremor, migraine prevention, and a few narrower cardiac indications.

It has been prescribed for performance nerves for about as long as it has existed, which puts it in the large category of drugs whose common use and whose approved use are different things. That gap is legal and ordinary, and it is covered further down.

How does propranolol work on performance anxiety?

Propranolol occupies the beta receptors that adrenaline uses, so the adrenaline your body releases has nowhere to bind. The nervous system still fires. The message stops at the receptor.

Adrenaline reaching beta-1 receptors in the heart is what raises your rate and the force of each beat. Adrenaline reaching beta-2 receptors in skeletal muscle produces the fine tremor that ruins a signature, a bow arm, or a hand holding a page. Block both and the heart rate stays near baseline, the tremor does not develop, and the voice keeps its tone. Sweating and flushing usually settle too.

What the drug cannot do is reach the fear. Propranolol crosses into the brain in small amounts, and the subjective dread of a performance comes from circuits it does not treat. Patients describe the split consistently: still nervous in the head, quiet in the body. For a great many people that split is enough, because the physical symptoms were the thing they were afraid of.

What dose of propranolol is used for performance anxiety?

The doses used for situational nerves are small: 10mg to 20mg, taken 60 to 90 minutes before the event, only on days it is needed. Higher doses give more blockade and more of the side effects, and they rarely improve the result for this purpose.

Peak blood levels arrive between 1 and 2 hours after an immediate-release tablet, and the half-life is roughly 3 to 6 hours, so a dose taken an hour ahead covers a performance and is mostly gone by evening. Long-acting propranolol, the once-daily capsule prescribed for blood pressure, is the wrong formulation here. You want a short window of cover instead of a day of it.

Three practical points carry most of the value:

• Take the first dose at home, on an ordinary day. An audition is a poor place to discover that 20mg makes you lightheaded. Take it on a Tuesday when nothing rides on the answer, and then you know what it does to you.
• Take it as needed, and not on a schedule. This is situational treatment. Daily use is a different clinical decision, and if you find yourself wanting it most days, tell your doctor, because the pattern has changed.
• Food changes absorption. Propranolol taken with a meal reaches somewhat higher levels than propranolol taken fasting. Keep it consistent, so the dose you tested at home behaves the same way on the day.

The page on dosage and timing works through all three questions people ask together: how much, how early, and how long it holds.

Who should not take propranolol?

Some conditions make propranolol unsafe at any dose, and for an elective use like this one there is no argument that outweighs them:

• Asthma, COPD, emphysema, or any reactive airway disease. Blocking beta-2 receptors in the airway can trigger bronchospasm. This is the firmest line on the page.
• A resting heart rate below about 55, or a clinician who has told you your rate runs slow.
• Second or third degree heart block, sick sinus syndrome, or a pacemaker.
• Decompensated heart failure or a reduced ejection fraction.
• Low blood pressure or a history of fainting.
• Any beta-blocker you already take, including eye drops for glaucoma, which are absorbed systemically.
• A previous adverse reaction to a beta-blocker.
• Pregnancy, trying to conceive, or breastfeeding.

A second group changes the calculation without closing the door, and each of these belongs in a conversation with a physician before anything is prescribed. Diabetes treated with insulin or a sulfonylurea comes first, because beta-blockade masks the tremor and pounding heart that warn you your glucose is falling. You lose the warning while the low happens anyway. Raynaud's phenomenon typically worsens. Thyroid disease, liver disease, myasthenia gravis, and any cardiac history each change the picture. So does rizatriptan for migraine, whose level rises on propranolol enough that the migraine dose has to come down. There is a page devoted to this list, who should not take propranolol, because it deserves more room than a bullet list gives it.

What about cardioselective beta-blockers if I have asthma?

Cardioselective agents such as atenolol and metoprolol favour beta-1 receptors and are used every day in people with mild airway disease when there is a cardiac reason to use them. The Cochrane review of cardioselective beta-blockade in reversible airway disease found they were tolerated in mild to moderate disease without a measurable fall in lung function.

The reasoning behind that review does not transfer to stage fright. Selectivity is relative and weakens as the dose rises, the patients in those trials had a cardiac indication that justified the risk, and a wedding toast is not a cardiac indication. Fishtown Medicine declines beta-blockade for performance anxiety in patients with reactive airway disease instead of routing them to a cardioselective substitute. If you have asthma and a service offers you atenolol for nerves off a web form, understand that a trade has been made on your behalf.

Selectivity does matter for a different reason. If you want the pharmacology in more depth, the page on metoprolol tartrate versus succinate walks through what changes when you change the form of a beta-blocker.

Guidance from the Clinic

"Every question on my screen is there because the answer changes what I do. If you have asthma I stop. If you use insulin I want to talk about what a low feels like to you, because I am about to take away the signal you rely on. None of that fits in a checkbox someone clicks on the way to a checkout page."

What are the side effects of propranolol?

At the small, occasional doses used for performance anxiety, most people notice very little. The effects people do report follow directly from the mechanism:

• Lightheadedness on standing, from a lower heart rate and blood pressure. The commonest complaint, and the reason to test a dose at home.
• Tiredness or heaviness in the legs, more noticeable if you exert yourself while it is working.
• Cold hands and feet, from beta-2 blockade in the peripheral vessels.
• Vivid dreams or disturbed sleep, since propranolol is lipophilic and enters the brain more than cardioselective agents do.
• A blunted heart rate response to exercise, which is a side effect for an athlete and the desired effect for a violinist.

Rare and serious effects belong to regular use more than to occasional use: worsening heart failure, marked bradycardia, bronchospasm in susceptible people, and masked hypoglycaemia. Each of these, and what to do about it, is covered at length on propranolol side effects. Stopping a long-standing daily beta-blocker abruptly can cause rebound tachycardia and angina, which is a reason never to inherit someone else's tablets and a reason a daily prescription is a different decision from an occasional one.

Does propranolol interact with alcohol, caffeine, or my other medicines?

Alcohol is the interaction most people meet, because these events come with a drink attached. Both alcohol and propranolol lower blood pressure, and together they can leave you lightheaded, so skip alcohol on a day you take it.

Caffeine works against the drug and against you. It raises circulating adrenaline and heart rate, which is the response you are treating. Two coffees before a presentation will undo part of the dose you took.

Among prescription medicines, the ones that matter most are other blood pressure and rhythm medicines, which compound the drop in rate and pressure; rizatriptan, whose blood level roughly doubles on propranolol so the migraine dose must be reduced; and drugs handled by the same liver enzymes, including some antidepressants and antipsychotics, which can raise propranolol levels. NSAIDs blunt the blood-pressure effect. Insulin and sulfonylureas are the interaction with the most at stake, for the reason given above.

Bring the whole list to the visit, including supplements. This is not a formality; it is the part of the review that most often changes the plan. The alcohol question gets its own page, propranolol and alcohol, because the two arrive at the same events by default.

Will propranolol affect my workout or my heart rate zones?

Yes, and this is the question nobody in the online prescribing category answers. Propranolol caps both your resting and your maximum heart rate for several hours. A training session taken after a dose will feel harder than the numbers on your watch suggest, your zones will read low, and your usual pace will fall into a band that no longer means what it meant last week.

The practical answer is scheduling. Train before you dose, or train on a different day. If you follow a structured plan, treat a propranolol day as a day the heart rate data is not comparable, and use perceived effort instead. Anyone whose training is built around zone 2 work or who watches resting heart rate and HRV as a recovery signal should expect both to be distorted the day they take it.

Is propranolol banned in sports?

Yes, in specific sports. The World Anti-Doping Agency prohibits beta-blockers under class P1, in competition and in some cases out of competition, in a defined list of sports where a steady hand or a slow heart rate confers an advantage. Archery, shooting, darts, billiards, and several others appear on it, which is to say the drug is banned in the sports where it works best.

If you are subject to testing at any level, check the current prohibited list before you take propranolol for any reason, including a cardiac indication, and ask about a therapeutic use exemption if there is a medical indication. A prescription is not a defence on its own. The sports, the timing of the ban, and how an exemption works are on are beta-blockers banned in sports.

Is off-label prescribing a problem?

Off-label prescribing is legal, common, and accounts for roughly one in five prescriptions written in United States office practice. It means the FDA reviewed propranolol for blood pressure, angina, arrhythmia, tremor, and migraine, and did not review it for performance anxiety, so a physician prescribing it for nerves is drawing on mechanism, published experience, and judgment in place of an approved indication.

What you deserve is to be told. Some services advertise "FDA-approved prescriptions" on a page selling a use the FDA never approved, which is technically true and leaves the wrong impression. You are receiving an approved drug for an unapproved purpose. That is a reasonable thing to do with your eyes open, and it is one of the questions to ask any service that will prescribe this to you over the internet.

How good is the evidence?

Thinner than the enthusiasm, and you should have the whole picture before deciding.

The direct evidence most often cited is Brantigan and colleagues in 1982, a small double-blind crossover trial in musicians that found beta-blockade reduced tremor and improved blinded judges' ratings of the performances. It is 40 years old and it is close to the whole of the controlled evidence for the musical case.

Steenen and colleagues published a systematic review and meta-analysis in 2016 of propranolol across anxiety disorders. They rated the quality of evidence low and did not find support for propranolol as a treatment for anxiety disorders as a class. That review concerns diagnosed disorders, which are different from situational nerves in a healthy person, so it does not settle this question. It does tell you the drug is used far more widely than the trial base underneath it.

The surveys reporting that a majority of orchestral musicians have used beta-blockers and found them helpful are surveys. They record belief and practice, and belief is not a controlled result.

Four things are true at once here: the mechanism is well understood, the safety profile is known from decades of cardiac use, the direct trial evidence is limited, and a great many people find it works. A page that gave you three of those four would be selling you something.

What does propranolol cost?

Generic propranolol is inexpensive. It has been off patent for decades, it appears on discount generic lists at most pharmacies, and a small quantity of 10mg tablets is one of the cheapest prescriptions in American retail pharmacy.

That fact should shape how you buy the care around it. There is nothing to be gained by having tablets marked up and mailed to you on a subscription, and a service that makes its margin on the pills has an interest in you taking more of them. What you are paying a physician for is the evaluation: the decision about whether this is your problem, the screen for the conditions that make it dangerous, and someone to reach when something changes. Fishtown Medicine's membership and pricing are published, and the prescription goes to whichever pharmacy is cheapest for you.

When is propranolol the wrong answer?

When the problem is not confined to the moment. If dread arrives on most days and is not attached to an event, if panic comes with no trigger, if you have begun declining work or avoiding social situations, or if you are using alcohol to get through these occasions, then blocking the tremor treats a symptom of something else and leaves the something else in place.

Those conditions are treatable, and they are treated differently. Cognitive behavioural therapy has a far stronger evidence base for social anxiety disorder than any beta-blocker, and daily medication is the right answer for some people. Sorting the situational from the general is most of the clinical work, and it is what online mental health treatment at Fishtown Medicine is set up to do. The page on anxiety versus physiology covers the reverse problem, where a physical cause is producing what looks like anxiety.

Related at Fishtown Medicine

• Performance anxiety: what your body is doing
• Who should not take propranolol
• A beta-blocker or a benzodiazepine?
• Propranolol dosage and timing
• Propranolol side effects
• Propranolol and exercise
• Metoprolol tartrate vs succinate

Scientific References

1. Brantigan CO, Brantigan TA, Joseph N. Effect of beta blockade and beta stimulation on stage fright. The American Journal of Medicine. 1982;72(1):88-94.
2. Steenen SA, van Wijk AJ, van der Heijden GJMG, van Westrhenen R, de Lange J, de Jongh A. Propranolol for the treatment of anxiety disorders: A systematic review and meta-analysis. Journal of Psychopharmacology. 2016;30(2):128-139.
3. Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for reversible airway disease. Cochrane Database of Systematic Reviews. 2005;(4):CD002992.
4. Radley DC, Finkelstein SN, Stafford RS. Off-label prescribing among office-based physicians. Archives of Internal Medicine. 2006;166(9):1021-1026.
5. US Food and Drug Administration. Inderal (propranolol hydrochloride) prescribing information. FDA Access Data.
6. World Anti-Doping Agency. The Prohibited List: P1 Beta-blockers.
7. Kenny DT. The Psychology of Music Performance Anxiety. Oxford University Press; 2011.
8. World Health Organization. WHO Model List of Essential Medicines.