What is the recommended dosage and usage of Hydroxyzine for anxiety and itching?

Hydroxyzine Dosage and Usage for Anxiety and Itching

For anxiety, hydroxyzine is recommended at 50-100 mg four times daily for adults, while for itching (pruritus), the recommended dosage is 25 mg three to four times daily. 1

Dosage Guidelines by Indication

For Pruritus/Itching:

• Adults: 25 mg three to four times daily 1
• Children under 6 years: 50 mg total daily dose, divided throughout the day 1
• Children over 6 years: 50-100 mg total daily dose, divided throughout the day 1

For Anxiety:

• Adults: 50-100 mg four times daily 1
• Children under 6 years: 50 mg total daily dose, divided throughout the day 1
• Children over 6 years: 50-100 mg total daily dose, divided throughout the day 1

For Sleep Induction:

• Adults: 10-50 mg at bedtime (when used as an adjunct to non-sedating antihistamines for patients with urticaria) 2, 3

Clinical Applications

For Dermatologic Conditions:

• Hydroxyzine is effective for managing pruritus associated with allergic conditions including chronic urticaria and atopic dermatoses 1
• For mild localized pruritus: Can be combined with topical treatments 2
• For moderate-severe pruritus: May be used with other oral antihistamines 2
  • Grade 1 pruritus: 10-25 mg four times daily or at bedtime 2
  • Grade 2-3 pruritus: 10-25 mg four times daily, may require addition of other therapies 2

For Anxiety Disorders:

• Hydroxyzine has demonstrated efficacy in generalized anxiety disorder (GAD) compared to placebo 4, 5
• Significant anxiolytic effect begins during the first week of treatment and is maintained throughout treatment periods 6
• Comparable efficacy to benzodiazepines and buspirone for GAD 4

Special Populations and Precautions

Renal Impairment:

• Moderate renal impairment: Dose should be halved 2, 3
• Severe renal impairment (creatinine clearance <10 mL/min): Avoid use 2

Hepatic Impairment:

• Severe liver disease: Avoid use due to inappropriate sedating effects 2, 3

Pregnancy:

• Contraindicated during early pregnancy 2, 3
• Generally best to avoid all antihistamines in pregnancy, especially during first trimester 2

Elderly:

• More sensitive to psychomotor impairment and at increased risk for complications like falls 3
• Consider lower starting doses

Side Effects and Monitoring

Common Side Effects:

• Sedation/drowsiness (most common) 4, 6
• Dry mouth 6
• Weight gain 6
• Loss of concentration 6

Important Considerations:

• Performance impairment may occur without subjective awareness of drowsiness 3
• Sleepiness typically appears during the first week and progressively diminishes with continued use 6
• Avoid concomitant use with alcohol, sedatives, hypnotics, or antidepressants due to enhanced performance impairment 3

Treatment Algorithm

1. For acute urticaria/itching:

   • Start with hydroxyzine 25 mg three to four times daily for adults 1
   • Consider adding a non-sedating antihistamine during daytime 2
   • For severe cases, consider short-term prednisone burst (shown to improve response) 7

2. For anxiety:

   • Begin with hydroxyzine 50 mg four times daily 1
   • Assess response after one week (efficacy typically begins within first week) 6
   • Continue for prescribed duration (efficacy maintained through treatment period) 5

3. For sleep induction in patients with pruritus:

   • Use hydroxyzine 10-50 mg at bedtime as an adjunct to daytime non-sedating antihistamines 2, 3

Clinical Pearls and Pitfalls

• Hydroxyzine can cause significant sedation that may impair driving and work performance 3
• When used for sleep in urticaria patients, it may help sleep quality but has limited additional clinical effect on the urticaria itself if H1 receptors are already saturated 2
• Abrupt discontinuation does not appear to cause rebound anxiety or withdrawal symptoms 6
• For patients requiring both daytime and nighttime symptom control, consider non-sedating antihistamines during the day and hydroxyzine at night 2