What is the role of Atarax (hydroxyzine) in treating anxiety?

Role of Hydroxyzine (Atarax) in Treating Anxiety

Hydroxyzine is indicated for short-term symptomatic relief of anxiety and tension associated with psychoneurosis, but its effectiveness for long-term use (beyond 4 months) has not been established by systematic clinical studies. 1

Mechanism and Indications

Hydroxyzine is an antihistamine medication with anxiolytic properties. According to the FDA label, it is approved for:

• Symptomatic relief of anxiety and tension associated with psychoneurosis
• As an adjunct in organic disease states with anxiety manifestations
• Management of pruritus due to allergic conditions
• As a sedative for premedication 1

Efficacy in Anxiety Treatment

While hydroxyzine has shown efficacy in treating anxiety:

• It is more effective than placebo for Generalized Anxiety Disorder (GAD) 2
• Studies have demonstrated good to excellent responses in 54-66% of patients with anxiety 3, 4
• Early effects on cognitive components of anxiety have been observed from the first week of treatment 5

However, the Cochrane review notes that due to high risk of bias in available studies, small sample sizes, and limited research, hydroxyzine cannot be recommended as a reliable first-line treatment for GAD 2.

Position in Treatment Algorithm

1. First-line treatments for anxiety disorders should be:

   • SSRIs or SNRIs combined with cognitive behavioral therapy 6
   • Examples include sertraline, escitalopram, venlafaxine, or duloxetine 6

2. Hydroxyzine's role is primarily as:

   • A short-term adjunctive treatment
   • An alternative when first-line treatments are contraindicated
   • An option for patients with comorbid insomnia due to its sedative properties 6, 5

3. Benzodiazepines may be considered for short-term relief in patients without history of dependency 6

Dosing Considerations

• The FDA label does not specify a standard dose for anxiety
• Clinical trials have used fixed doses of 50 mg with positive results 5
• Dosing should start low and be adjusted based on response and tolerability

Side Effects and Safety Considerations

Common side effects include:

• Transitory sleepiness/drowsiness (36% of patients) 3
• Weakness (18%) 3
• Headache (6%) 3
• Dry mouth (2%) 3

Important safety considerations:

• Hydroxyzine has no dependency potential, unlike benzodiazepines 5
• No significant organ toxicity has been reported 5
• Rare allergic reactions may occur 3
• Potential drug interactions should be monitored, particularly when combined with other CNS depressants
• Caution is warranted when combining with medications that have alpha-adrenergic antagonist properties, as there is a case report of priapism when hydroxyzine was added to risperidone 7

Use in Special Populations

For children and adolescents:

• Hydroxyzine (along with diphenhydramine) has been used for management of agitation 8
• It may be considered as an alternative to antipsychotics or benzodiazepines in certain situations 8
• However, current guidelines for anxiety disorders in children and adolescents primarily recommend CBT and SSRIs 8

Limitations

• The effectiveness of hydroxyzine for anxiety beyond 4 months has not been established 1
• Physicians should periodically reassess the usefulness of the drug for individual patients 1
• Sedation may limit its use in patients who need to remain alert during the day

Conclusion

While hydroxyzine has demonstrated efficacy for short-term anxiety relief, its role in modern anxiety treatment is primarily as an adjunctive or alternative option rather than first-line therapy. Its favorable safety profile (non-habit forming, minimal organ toxicity) makes it a consideration for specific patient populations, particularly those with comorbid insomnia or when SSRIs/SNRIs are contraindicated.