Propranolol: Your Questions Answered

It’s a drug you’re not quite sure how to pronounce and you’re quite certain comes with a long list of risks and side effects. Aside from that, you may know very little about propranolol. 

If you’ve heard there’s a chance it could help you with the fear that grips you before a performance or public speaking event, you’re on the right track. Propranolol is generally used to treat high blood pressure, but is also sometimes prescribed for the off-label treatment of the physical symptoms of performance or situational anxiety. 

Like all prescription drugs, you should learn about propranolol before taking it. You’re putting it in your body, for goodness’ sake — you owe it to yourself to know as much about it as possible.

Luckily, we’ve anticipated your most burning questions about the drug and how it works. 

What is propranolol? 

Propranolol belongs to a class of drugs called beta-blockers. It, like other drugs in this class, is primarily approved for use in the treatment of high blood pressure, a condition that affects more than 100 million Americans.

It is also approved for use in treating tremors and irregular heartbeats and for the prevention of migraines. 

Propranolol is also used off-label, or in ways not explicitly approved by the FDA. For instance, it is sometimes prescribed off-label for the treatment of the physical symptoms of performance anxiety, also known as “stage fright.”

How does propranolol work? 

Beta-blockers such as propranolol work by blocking the effects of adrenaline, also known as epinephrine. Epinephrine is the hormone that rushes into your system when you are scared or excited. Think roller coaster rides or bungee jumping — does your heartbeat quicken? That’s just a taste of adrenaline. 

Actually doing those activities causes a dump of the hormone, leading to a physical response like rapid heart rate, sweating, faster breathing, heightened senses, nervousness and decreased ability to feel pain. 

When confronted with a bear in the woods, it may help you get away faster. When confronted with a presentation at work, however, it could be extremely disruptive. 

What is “performance anxiety”?

Performance anxiety is a type of social phobia and has symptoms in common with general anxiety — fear, restlessness, high blood pressure, tremors, sweating, nausea and high heart rate, for example.

But unlike general anxiety, performance anxiety only arises in situations where you’ll be “on the spot.” Job interviews, presentations at work, a speech at your best friend’s wedding, a big race — any one of these can cause performance anxiety. 

You could have diagnosable performance anxiety if you’ve experienced these symptoms consistently for six months or more, it causes extreme distress and the fear you feel is unrealistic given the circumstances at hand. 

Our guide to dealing with performance anxiety goes into what, exactly, it is, and explores methods by which you can control it — with or without beta blockers. 

What is the evidence that it’s effective for helping with performance anxiety?

Several studies have evaluated whether propranolol and other beta blockers are sound treatments for performance anxiety. And many of these studies supported the use of beta blockers like propranolol to help with performance anxiety-related symptoms. 

Overall, propranolol has been found to reduce high heart rate, tremors, excessive sweating and feelings of nervousness and fear. 

For example, one study looked at surgical residents and found that in the five resident surgeons monitored during 73 total cases over the span of 10 weeks, performance greatly improved. 

The resident surgeons were given 40mg of propranolol approximately one hour before surgery, and each surgeon (and their attending surgeon observer) were given a grading form after every case.

The study monitored things like general anxiety and hand tremors, and found that in the majority of cases, the surgeons performed better and suffered less anxiety after having taken propranolol than a placebo.

In another analysis, study subjects were given a propranolol dosage of 40mg and asked to give a speech, which was videotaped. Analyzing the video tapes and the speakers self-reported symptoms, the researchers found both physical and verbal signs of anxiety were decreased with propranolol use. 

And another double-blind study looked at the effects of propranolol on a group of 29 musicians. The musicians were selectively given propranolol prior to a performance, which was judged by esteemed music critics. The study found that in the musicians given propranolol, the physical impediments related to performance anxiety were blocked, which resulted in an overall better quality performance.

Is propranolol safe? 

Propranolol has been sold in the U.S. for over 40 years. That doesn’t mean it doesn’t come without risks — all drugs do. Among the more serious risks of this drug: Changes in blood sugar level and the concealment of symptoms of low blood sugar, loss of alertness, allergic reactions, skin reactions (such as blistering or peeling) and heart failure. 

These risks are rare, but be sure to check with your doctor right away if you experience any symptoms of these risks after taking propranolol such as chest pain, shortness of breath, rapid heart beat or swelling. 

Propranolol can also increase the effect of alcohol or other depressants. What this means is you may want to practice restraint if you’re thinking about throwing back cocktails after you’ve taken a propranolol. 

Since propranolol slows your heart rate, you should talk with your doctor if you have a heart condition or are otherwise concerned about the potential cardiovascular effects of propranolol. 

You may also experience side effects while taking propranolol. Again, all drugs have them, as you’re well aware if you’ve ever heard a prescription drug commercial. Common propranolol side effects include dizziness, diarrhea, tiredness and constipation. 

But is it safe even when prescribed “off-label”?

When a drug is approved for use in the U.S., the FDA’s label for that drug outlines very specific uses. The FDA’s approval is based on review of data from clinical trials and other information supporting those specific uses, including information about the effectiveness and safety of the drug.

】Performance anxiety is not on the label for propranolol, but that doesn’t mean it’s less safe to take for that condition. 

Sometimes doctors will prescribe drugs “off-label” as it’s called, when there is evidence — either from use of a drug in the “real world” (e.g., not in a clinical trial) or other scientific or clinical bases — that support the effectiveness and safety of a drug for a use that is not on the drug’s label. 

The FDA says, “Once the FDA approves a drug, healthcare providers generally may prescribe the drug for unapproved (off-label) use when they judge it is medically appropriate for their patient.”

If your doctor thinks it’s appropriate to prescribe you propranolol to help control the physical symptoms of your performance anxiety, they will discuss with you the possible risks and potential side effects.

And if your doctor prescribes you propranolol to help control the physical symptoms of performance anxiety, it will likely be a different dosage than if you were taking it for hypertension or to prevent migraines.

You and your doctor can decide if it’s the best choice for you.