Can hydroxyzine be used for insomnia?

Hydroxyzine for Insomnia Management

Hydroxyzine is not recommended as a first-line treatment for insomnia due to limited efficacy evidence, safety concerns including QT prolongation risk, and the availability of more effective alternatives. 1, 2, 3

Efficacy and Evidence Assessment

Hydroxyzine's use for insomnia lacks strong supporting evidence:

• Current insomnia management guidelines do not include hydroxyzine among recommended medications for insomnia 1
• The most recent systematic review (2023) found only 5 studies evaluating hydroxyzine for sleep, with mixed efficacy results for sleep onset, maintenance, and quality 3
• The American Academy of Sleep Medicine and American College of Physicians recommend CBT-I as first-line treatment, with specific FDA-approved medications as pharmacological options 1

Safety Concerns

Hydroxyzine carries several important safety risks:

• QT prolongation and Torsade de Pointes: Case reports document this potentially life-threatening adverse effect, particularly in patients with risk factors 4, 5
• CNS depression: Hydroxyzine potentiates other CNS depressants including narcotics and barbiturates 4
• Suicide risk: A comparative safety study found 61% higher hazard of suicide attempt with trazodone compared to zolpidem, raising concerns about off-label sedating medications 6
• Other adverse effects: Includes dry mouth, daytime drowsiness, and rare but serious skin reactions like acute generalized exanthematous pustulosis 4, 3
• Drug interactions: Particularly concerning with other QT-prolonging medications 4

Recommended Alternatives

Guidelines recommend the following evidence-based approaches for insomnia:

1. First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) 1, 2

   • Includes stimulus control, sleep restriction, cognitive therapy, and relaxation training
   • Can be delivered face-to-face, via telehealth, or through self-directed internet programs

2. Pharmacological options (if CBT-I ineffective or unavailable) 1:

   • For sleep onset insomnia: Zolpidem (10mg adults, 5mg elderly), zaleplon (10mg), ramelteon (8mg)
   • For sleep maintenance insomnia: Doxepin (3-6mg), eszopiclone (2-3mg), suvorexant (10-20mg)

Special Considerations

• Elderly patients: Start with lower doses; hydroxyzine particularly problematic due to anticholinergic effects and fall risk 4
• QT prolongation risk factors: Avoid hydroxyzine in patients with pre-existing heart disease, electrolyte imbalances, or concomitant use of other QT-prolonging medications 4, 5
• Monitoring: If hydroxyzine is used despite concerns, monitor for QT prolongation with ECG and electrolyte levels 5

Clinical Decision Algorithm

1. Assess for insomnia type: Determine if patient has sleep onset, maintenance, or mixed insomnia
2. First recommend CBT-I regardless of insomnia type
3. If pharmacotherapy needed:
   • Choose FDA-approved medication based on insomnia type from guideline-recommended options 1
   • Consider hydroxyzine only if:
     • Other treatments have failed or are contraindicated
     • No risk factors for QT prolongation exist
     • Short-term use only
     • Starting at lowest effective dose

Common Pitfalls

• Off-label prescribing: Despite common practice, evidence for hydroxyzine in insomnia is limited 2, 3
• Underestimating risks: QT prolongation, anticholinergic effects, and potentiation of other CNS depressants 4, 5
• Overlooking drug interactions: Particularly with other QT-prolonging medications 4
• Long-term use: Hydroxyzine should only be considered for short-term use if at all 3