[pshrinkery, med] Q re propranolol (Inderal) for anxiety

[siderea]

MDs, pharmacists, other Rx'ers, and medicine geeks: Is there some reason that propranolol is not more widely prescribed for anxiety? Like, in my reality, at all?I have a patient who is elderly, had a bad reaction to benzodiazepines such that nobody sane will ever prescribe them to her, and raging agoraphobia. Her psychiatrist has only offered her

Comments

Personal experience...

[thetimesink]

Rx routinely used for BP and relatively recently for migraines. In some users (cohort=two) it absolutely banished migraines (headache) and in one case unveiled a previously unknown visual migraine when DCd as no longer needed for BP.

No effect in one case regarding anxiety/depression related panic attacks (clonazepam effective).

FWIW

Propranolol for anxiety

[anonymous]

(Am an internal medicine resident in an academic center. Have prescribed propranolol for performance anxiety; also for unavoidable airplane travel for people who really should not be taking sedatives and have specific phobias related to flying

Re: Propranolol for anxiety

[siderea]

Hypothesis1: Propranolol is not seen in your world because there is moderate evidence beta blockers have a class effect of causing/worsening depression, and you see lots of people who either have depression or are at risk for it.

AH! That's good to know. Glad I asked.

ETA: The internet tells me 10mg taken an hour before needed is a standard dose for performance anxiety: how long is that typically good for? How often may a person safely take that dose in a day?

Also do you know why it's (apparently?) exclusively rx'd for situational anxiety, and not generalized anxiety?

Re: Propranolol for anxiety

[much_ado]

Direct anecdotal intel, take for what it's worth:

I am taking propranolol for migraine prevention, 40mg 3x/day. This round, I've now been on it for just over a year. 1st round, I was on it for about nine months, and can absolutely verify the deepening impact on existing depression to the point of suicidal ideation (that last part was how I finally figured out it was the drug and not me, and promptly began weaning myself off it). This time around, no ideation; the depression and fatigue are persistent but manageable, with no effect whatsoever on occasional anxiety surges. My blood pressure when checked reads normal or only slightly lower than normal, but I wear the MedicAlert bracelet for hypotension anyway. My GP assures all of this is "normal", and I would assume that the occasionally-unpredictable hypotension plus the known risk of worsening depression might be part of the reason why it's not prescribed often for general anxiety.

RE: Re: Propranolol for anxiety

[anonymous]

Half life is 3-5 hours. Maximum tolerated dose is very high compared to these doses (we use much much higher doses for things like angina).

And I do not believe it has been shown to be more effective than placebo in generalized anxiety disorder. I would be interested in any evidence to the contrary.

-- Your friendly internal medicine resident

[gipsieee]

I don't recall exactly what answer was given, but I think someone muttered something to the effect of "doesn't work/can't feel it's working so patients don't like it" when I asked the same question at school, but I wouldn't have gotten any further data or evidence to support that, just the prof's off the cuff answer, so I can't tell you if there's been any study to back it up.

[ladysprite]

I know when he thought my GI issues were being caused by anxiety, my gastroenterologist put me on propanolol.

(No effect, mostly because that wasn't the problem, but just a data point that it is being used....)

[siderea]

What's fascinating to me is that all the reports I have of physicians prescribing it for psychiatric purposes are non-psychiatrists, and I don't know any actual psychiatrists prescribing it.

Now I'm hoping some actual psychiatrists chime in to speak for themselves. This is so odd.

[therck]

I know that, for me, all beta blockers are out of the question because I have asthma. They can do really, really nasty things in that direction, so if the patient in question has some sort of respiratory issue, that might have an effect on whether or not the medication is feasible.

It's a pity because, from what I gather, my anxiety problems are exactly the sort of thing that beta blockers help with, but there isn't currently a rescue inhaler on the market that I can use safely.

[siderea]

Hmm! Good to know. Any idea how beta blockers exacerbate asthma?

[therck]

A little bit of Google searching seems to indicate that there are two sub-groups of beta blockers. There's some indication that cardioselective beta blockers may be safe, possibly even beneficial, for folks with asthma or COPD, but the other type are potentially quite dangerous.

These two papers give some information:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709648/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC482795/

The first one specifically excludes any studies done before 1985, and the second one was done in 1979.

I'm not certain of the reliability of this site, but here's a bit of what they say. It's in much clearer language than the NIH papers

[siderea]

HUH! Fascinating. I'm glad I asked.