Can I give hydroxyzine to a patient on Suboxone (buprenorphine)?

Hydroxyzine Can Be Used with Buprenorphine but Requires Monitoring

Hydroxyzine can be administered to patients on Suboxone (buprenorphine/naloxone), but dose adjustment and monitoring are recommended due to possible drug interactions that may increase hydroxyzine exposure. 1

Drug Interaction Analysis

Hydroxyzine and buprenorphine have a potential interaction that requires clinical attention:

• According to perioperative drug interaction guidelines, hydroxyzine has a "possible interaction" with lopinavir/ritonavir that may require dose adjustment or monitoring, but no significant interaction with buprenorphine is specifically noted 1
• The FDA label for buprenorphine warns about additive CNS depressant effects when combined with other sedating medications, which would include hydroxyzine 2

Clinical Considerations

CNS Depression Risk

• Buprenorphine can cause drowsiness and slow reaction times, especially during the first few weeks of treatment 2
• Hydroxyzine is sedating and may compound these effects
• The combination could potentially increase risk of:
  • Excessive sedation
  • Impaired cognitive function
  • Respiratory depression (though this is less likely than with full opioid agonists)

Cardiac Considerations

• Hydroxyzine may produce abnormal ventricular repolarization in susceptible individuals or at high doses 3
• This effect could theoretically be problematic when combined with other medications that affect cardiac conduction

Recommended Approach

1. Start with lower doses of hydroxyzine when administering to patients on Suboxone
2. Monitor for excessive sedation after administration
3. Warn patients about potential additive effects on alertness, coordination, and driving ability
4. Avoid alcohol while taking this combination, as it could lead to dangerous levels of sedation 2
5. Use caution in patients with:
   • Respiratory conditions
   • Advanced age
   • Liver impairment
   • Concurrent use of other CNS depressants

Important Precautions

• Patients should be advised not to drive or operate heavy machinery until they know how this combination affects them 2
• Be aware that buprenorphine has been reported to trigger serotonin syndrome in rare cases when combined with serotonergic medications 4
• If the patient shows signs of excessive sedation, consider reducing the hydroxyzine dose

Conclusion

While hydroxyzine can be used with buprenorphine, the combination requires careful monitoring for additive sedative effects. The benefits of hydroxyzine for anxiety or as an antihistamine should be weighed against the potential risks of increased sedation when combined with Suboxone.