From the Guidelines
Hydroxyzine is not absolutely contraindicated in chronic kidney disease (CKD), but dose adjustments are typically recommended to minimize potential harms. For patients with CKD, the hydroxyzine dose should generally be reduced by 25-50% of the standard dose, depending on the severity of kidney impairment, as supported by the KDOQI commentary on the KDIGO 2024 clinical practice guideline 1. This is because hydroxyzine is partially metabolized by the kidneys, and reduced renal clearance can lead to drug accumulation and increased risk of side effects such as excessive sedation, confusion, and anticholinergic effects.
When prescribing hydroxyzine to patients with CKD, it is essential to consider the benefits versus potential harms, as emphasized in the KDIGO 2024 clinical practice guideline 1. The medication's half-life is prolonged in patients with impaired kidney function, which necessitates these dosing modifications. Patients with CKD should be monitored more closely for adverse effects when taking hydroxyzine, particularly elderly patients who may be more sensitive to its sedative properties.
Some key considerations for prescribing hydroxyzine in CKD patients include:
- Monitoring eGFR, electrolytes, and therapeutic medication levels, when indicated, to minimize the risk of nephrotoxicity and adverse effects 1
- Reviewing and limiting the use of over-the-counter medicines and dietary or herbal remedies that may be harmful for people with CKD 1
- Providing comprehensive medication management to ensure each patient's medications are individually assessed for appropriateness, effectiveness, safety, and ability to be taken as intended 1
- Considering alternative medications with less renal impact if a patient with CKD experiences increased side effects despite dose reduction.
By taking a cautious and individualized approach to prescribing hydroxyzine in CKD patients, clinicians can help minimize potential harms and optimize patient outcomes, as recommended by the KDOQI Work Group 1.
From the Research
Hydroxyzine Use in Chronic Kidney Disease
- Hydroxyzine is not explicitly contraindicated in chronic kidney disease, but its use requires caution 2, 3.
- Studies have shown that hydroxyzine can be effective in treating pruritus in patients with end-stage renal disease (ESRD) 2, 3.
- However, the safety profile and dosing information of hydroxyzine in patients with ESRD are not well-established 4.
- The pharmacokinetics of hydroxyzine in patients with renal insufficiency have not been extensively studied, but a study on loratadine, a similar antihistamine, found that its disposition was not significantly altered in patients with severe renal insufficiency 5.
- Hydroxyzine has been compared to other treatments for uremic pruritus, such as gabapentin, Avena sativa, and vinegar, and has been found to be effective in reducing pruritus intensity 2, 3.
Considerations for Use
- Clinicians should use caution when prescribing hydroxyzine to patients with chronic kidney disease, due to the lack of established safety and dosing guidelines 4.
- Patients with ESRD may be at risk for medication therapy problems related to safety, effectiveness, appropriateness, and adherence, and medication management strategies should be implemented to minimize these risks 6.
- Hydroxyzine may be used in conjunction with other treatments for uremic pruritus, such as Avena sativa and vinegar, to provide complementary relief 3.