From the Guidelines
For a patient whose anxiety is not adequately controlled with hydroxyzine 10mg, I recommend starting buspirone, typically beginning at 5mg twice daily and gradually increasing to 15-30mg daily in divided doses, as it is a non-controlled medication option with a different mechanism of action compared to hydroxyzine. When considering alternative options, it's essential to note that SSRIs, such as sertraline or escitalopram, can interact with various medications, including monoamine oxidase inhibitors (MAOIs), and may have discontinuation syndrome associated with them, as reported in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. Some key points to consider when prescribing these medications include:
- Starting with a low dose and gradually increasing it to minimize side effects
- Monitoring for symptoms, especially in the first 24 to 48 hours after dosage changes
- Being aware of potential drug-drug interactions, particularly with MAOIs and medications that prolong the QT interval
- Considering the potential for discontinuation syndrome when stopping or reducing the dose of SSRIs, especially paroxetine, fluvoxamine, and sertraline 1. Alternatively, an SSRI such as sertraline (starting at 25-50mg daily) or escitalopram (starting at 5-10mg daily) would be appropriate non-controlled medication options, but it's crucial to weigh the benefits and risks, including the potential for increased anxiety or agitation as an initial adverse effect, as noted in the guideline 1. Beta-blockers like propranolol (10-40mg as needed) could also be considered for situational anxiety with prominent physical symptoms, but the primary recommendation remains starting buspirone due to its efficacy and relatively favorable side effect profile compared to other options.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Non-Control Medication Options for Anxiety
If hydroxyzine 10mg is not effective for anxiety, there are other non-control medication options that can be considered.
- Buspirone: According to the study 2, hydroxyzine was equivalent in terms of efficacy, acceptability, and tolerability compared to buspirone.
- Selective serotonin reuptake inhibitors (SSRIs): Studies 3 and 4 suggest that SSRIs such as fluvoxamine, fluoxetine, paroxetine, sertraline, and citalopram can be effective in treating anxiety disorders, including generalized anxiety disorder and panic disorder.
- Benzodiazepines: Although benzodiazepines can be effective in treating anxiety, the study 2 notes that hydroxyzine was equivalent in terms of efficacy, acceptability, and tolerability compared to benzodiazepines like chloridiazepoxide.
Considerations for Co-Administration
When considering co-administration of an antidepressant and an anxiolytic drug, the study 3 suggests that hydroxyzine may be a better option than benzodiazepines, as it does not antagonize the effects of SSRIs like fluvoxamine or fluoxetine.
Efficacy and Safety of Alternative Medications
The study 5 demonstrates the efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder over a 3-month period, with results comparable to bromazepam. However, if hydroxyzine is not effective, other medications like SSRIs or buspirone may be considered as alternative treatment options.