Is hydroxyzine (an antihistamine) 25 mg suitable for treating anxiety in this patient?

Hydroxyzine for Anxiety Management

Hydroxyzine 25 mg is an appropriate medication for treating anxiety in this patient, as it is FDA-approved for symptomatic relief of anxiety and tension associated with psychoneurosis. 1

Mechanism and Efficacy

Hydroxyzine is a first-generation antihistamine with anxiolytic properties that has demonstrated efficacy in treating generalized anxiety disorder:

• Clinical trials have shown hydroxyzine to be superior to placebo in reducing anxiety symptoms, with effects noticeable from the first week of treatment 2, 3
• It targets cognitive components of anxiety particularly well 3
• The FDA has approved hydroxyzine specifically for "symptomatic relief of anxiety and tension associated with psychoneurosis" 1

Dosing Considerations

• The standard dosing for anxiety is 25-50 mg, with 25 mg being an appropriate starting dose 1
• For elderly or debilitated patients, consider starting with a lower dose
• The medication can be taken up to four times daily as needed

Advantages Over Other Anxiolytics

Hydroxyzine offers several advantages compared to benzodiazepines:

• No risk of dependency or addiction 3
• No evidence of organ toxicity with long-term use 3
• Can be used safely in patients with a history of substance abuse
• Does not require special monitoring or controlled substance prescribing protocols

Potential Side Effects and Monitoring

The most common side effect is sedation/drowsiness, which occurs more frequently than with some other anxiolytics 2:

• Warn the patient about potential drowsiness, especially when starting treatment
• Advise against driving or operating machinery until the patient knows how the medication affects them
• Sedation may diminish with continued use on the same dosage 4

Clinical Pearls and Pitfalls

• Hydroxyzine can be particularly useful for patients with comorbid anxiety and pruritus or allergic conditions 1
• It may potentiate the effects of opioids and barbiturates, so dosage adjustments may be necessary if the patient is on these medications 1
• Unlike benzodiazepines, hydroxyzine can be stopped abruptly without tapering, though gradual discontinuation is generally preferred 5
• The medication can be used as a short-term intervention or for longer periods, though reassessment of its usefulness should be conducted periodically 1

Follow-up Recommendations

• Evaluate response after 1-2 weeks of treatment
• If 25 mg is insufficient, consider increasing to 50 mg
• For patients experiencing excessive sedation, consider reducing the dose or administering primarily at bedtime

Hydroxyzine represents a reasonable non-benzodiazepine option for anxiety management with a favorable safety profile and established efficacy.