What is the appropriate discharge medication and dosage for an 86-year-old male with anxiety and shortness of breath who improved with hydroxyzine (hydroxyzine) 50 mg in the emergency department (ED)?

From the Guidelines

For an 86-year-old male with anxiety and shortness of breath who responded well to hydroxyzine 50 mg in the ED, I recommend prescribing hydroxyzine 25 mg orally three times daily as needed for anxiety and shortness of breath, with a limited supply. This recommendation is based on the principle of using the lowest effective dose, especially in elderly patients, to minimize potential side effects such as anticholinergic and sedative effects, as suggested by general principles of geriatric pharmacotherapy 1. Key considerations in managing this patient's anxiety include:

• Monitoring for excessive sedation, confusion, urinary retention, dry mouth, and constipation, which are potential side effects of hydroxyzine.
• Advising the patient to avoid alcohol and other CNS depressants while taking this medication to prevent adverse interactions.
• Scheduling a follow-up appointment within a short timeframe (e.g., 1-2 weeks) to assess the effectiveness of the medication and any adverse effects, with potential dose adjustments based on response. The choice of hydroxyzine and its dosage should be informed by the patient's response to the initial dose in the ED, as well as considerations of potential drug interactions and the patient's overall health status, in line with principles of personalized medicine and caution with medication use in the elderly 1.

From the FDA Drug Label

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy Sedating drugs may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of hydroxyzine and observed closely.

The patient was given 50 mg of hydroxyzine in the emergency department and reported improvement in symptoms. Given the patient's age (86 years old), it is recommended to exercise caution when selecting a dose. The dose for discharge should be at the low end of the dosing range. However, the exact dose is not specified in the label. Considering the patient's response to the initial dose, a reasonable approach would be to continue with a low dose, such as 25-50 mg, and monitor the patient closely for any adverse effects 2.

From the Research

Disposition and Medication for 86-year-old Male with Anxiety

• The patient, an 86-year-old male, presented with anxiety and shortness of breath, which improved with hydroxyzine 50 mg administered in the emergency department.
• For discharge medication, the goal is to manage the patient's anxiety while considering potential side effects and interactions.
• Hydroxyzine is an antihistamine that can be used for anxiety, as mentioned in studies 3, 4.
• The appropriate dosage of hydroxyzine for discharge is not explicitly stated in the provided studies, but the studies mention various dosages such as 25 mg, 50 mg, or 100 mg 5.
• Considering the patient's improvement with 50 mg in the emergency department, a reasonable approach might be to prescribe a similar or slightly lower dosage for home use, taking into account the patient's age and potential sensitivity to medications.
• However, it is essential to consult the patient's medical history, other medications, and potential interactions before determining the final dosage.
• Studies suggest that hydroxyzine could be considered as a short-term treatment option for adults with insomnia or anxiety 5, but long-term use and potential side effects should be monitored.

Considerations for Hydroxyzine Dosage

• The patient's response to 50 mg in the emergency department suggests that this dosage may be effective for managing anxiety.
• However, the patient's age and potential comorbidities should be considered when determining the discharge dosage.
• A lower dosage, such as 25 mg, may be considered to minimize potential side effects, but this should be based on individual patient assessment.
• Regular follow-up and monitoring of the patient's response to the medication, as well as potential side effects, are crucial for adjusting the dosage as needed.

Additional Considerations

• The patient's shortness of breath, potentially related to anxiety, should be monitored and addressed in the discharge plan.
• Other medications or therapies that may interact with hydroxyzine or exacerbate the patient's condition should be considered and avoided if possible.
• Education on proper use, potential side effects, and follow-up appointments should be provided to the patient and caregivers to ensure safe and effective management of anxiety.