Can hydroxyzine be added to a regimen of buspirone and citalopram for anxiety?

From the Guidelines

I strongly advise against adding hydroxyzine to your current regimen of buspirone and citalopram without consulting your healthcare provider first, as combining these medications can lead to increased risk of side effects such as excessive sedation, dizziness, and cognitive impairment 1. When considering the addition of hydroxyzine, it's crucial to evaluate the potential interactions with your current medications, buspirone and citalopram. Some key points to consider include:

• The risk of serotonin syndrome when combining SSRIs, like citalopram, with other serotonergic agents, although hydroxyzine is not typically considered a significant risk for this condition 1.
• The potential for increased sedation and cognitive impairment due to the additive effects of hydroxyzine and buspirone, both of which can cause drowsiness 1.
• The importance of monitoring for QT prolongation when using citalopram, especially at doses exceeding 40 mg/d, and considering the potential impact of adding another medication to your regimen 1. Given these considerations, your healthcare provider should carefully assess your specific anxiety symptoms, the effectiveness of your current medications, and your overall health status before making any changes to your treatment plan. They may consider alternative strategies, such as:
• Adjusting the dosages of your existing medications to optimize their effectiveness
• Switching one medication for another that may be more effective or have a more favorable side effect profile
• Adding hydroxyzine as an as-needed option for breakthrough anxiety, rather than a regular part of your daily regimen 1.

From the Research

Combination Therapy for Anxiety

The use of buspirone and citalopram for anxiety is a common practice, and adding hydroxyzine to this combination has been studied in various research papers.

• The efficacy of hydroxyzine in treating generalized anxiety disorder (GAD) has been compared to placebo and other anxiolytic agents, such as buspirone, in a study published in 2010 2.
• The results showed that hydroxyzine was more effective than placebo and equivalent to other anxiolytic agents, including buspirone, in terms of efficacy, acceptability, and tolerability.
• Another study published in 2011 reviewed the effectiveness of alternative and augmenting medications, including hydroxyzine, for the treatment of GAD 3.
• The study found that hydroxyzine was one of the most effective medications, along with imipramine, valproate, and pregabalin, in reducing symptoms of GAD.
• A review of current pharmacological treatments for anxiety disorders, including GAD, published in 2020, listed hydroxyzine as an antihistamine medication that can be used to treat anxiety 4.
• The review also mentioned that buspirone, an azapirone, is a commonly used medication for anxiety disorders.
• A treatment review published in 2018 recommended SSRIs and SNRIs as first-line pharmacotherapy for adults with GAD, while buspirone, benzodiazepines, and pregabalin were considered second-line options 5.
• Hydroxyzine was not specifically mentioned as a first-line or second-line option in this review.

Safety and Efficacy Considerations

When considering adding hydroxyzine to a combination of buspirone and citalopram, it is essential to weigh the potential benefits and risks.

• The study published in 2010 found that hydroxyzine was associated with a higher rate of sleepiness/drowsiness compared to other anxiolytic agents 2.
• The review published in 2020 noted that there is a lack of randomized double-blind placebo-controlled trials for anxiety disorders, and few studies have compared novel treatments to existing anxiolytic agents 4.
• The treatment review published in 2018 emphasized the importance of considering multiple factors, including age, co-morbidity, and prior treatment, when selecting pharmacotherapy for GAD 5.
• Benzodiazepines, which are sometimes used to treat anxiety, have a high potential for dependence and withdrawal symptoms, as discussed in a study published in 2021 6.