What is the role of Vistaril (hydroxyzine) in managing nighttime anxiety?

Vistaril (Hydroxyzine) for Nighttime Anxiety

Hydroxyzine is an effective option for managing nighttime anxiety, with particular benefits due to its sedative properties that can help with sleep initiation while providing anxiolytic effects. 1

Mechanism and Indications

Hydroxyzine is a first-generation antihistamine that is FDA-approved for:

• Symptomatic relief of anxiety and tension associated with psychoneurosis
• Management of pruritus due to allergic conditions
• Use as a sedative for premedication 1

Dosing for Nighttime Anxiety

• Standard adult dosing: 25-50 mg at bedtime
• Elderly patients: Consider starting at lower doses (10-25 mg)
• Duration: While effective for short-term use, the effectiveness for anxiety beyond 4 months has not been systematically evaluated 1

Efficacy for Anxiety

Hydroxyzine has demonstrated superior efficacy compared to placebo in treating generalized anxiety disorder:

• Shows significant improvement over placebo starting from the first week of treatment 2
• Maintains anxiolytic effects throughout treatment periods 3
• Comparable efficacy to benzodiazepines and buspirone in clinical trials 3

Benefits for Nighttime Use

1. Dual action: Provides both anxiolytic and sedative effects
2. Sleep induction: Sedative properties help with sleep initiation 4
3. Reduced rhinorrhea: Can reduce nasal symptoms that may disturb sleep 4
4. Non-habit forming: Unlike benzodiazepines, hydroxyzine does not cause dependence 5
5. No rebound anxiety: Studies show no rebound anxiety after discontinuation 2

Cautions and Side Effects

• Sedation: Most common side effect (28% vs 14% with placebo), typically transient and diminishing with continued use 2
• Performance impairment: May cause next-day drowsiness and impair driving or work performance 4
• Anticholinergic effects: Can cause dry mouth, constipation, and urinary retention 4
• Contraindications:
  • Early stages of pregnancy 4
  • Severe hepatic impairment 4
  • Elderly patients are more sensitive to psychomotor impairment and at increased risk for falls 4

Alternative Approaches to Consider

If hydroxyzine is not appropriate or effective, consider:

1. Non-pharmacological options (first-line for chronic insomnia):

   • Cognitive Behavioral Therapy for Insomnia (CBT-I) 6
   • Image Rehearsal Therapy for anxiety-related nightmares 6
   • Progressive Deep Muscle Relaxation before bedtime 6

2. Alternative medications:

   • Trazodone: Effective for reducing nightmare frequency (mean effective dose 212 mg/day) 4
   • Doxepin (3-6 mg): Effective for sleep maintenance insomnia 6
   • Mirtazapine (7.5-15 mg): When rapid symptom relief is needed 6

Clinical Decision Algorithm

1. For mild to moderate nighttime anxiety with sleep disturbance:

   • Start with hydroxyzine 25-50 mg at bedtime
   • Monitor for effectiveness and side effects after 1-2 weeks
   • If effective but causing daytime sedation, adjust timing to earlier in the evening

2. For severe anxiety or if hydroxyzine is ineffective:

   • Consider combining hydroxyzine with CBT techniques
   • Or switch to alternative medication based on symptom profile

3. For elderly patients or those with comorbidities:

   • Start with lower dose (10-25 mg)
   • Monitor closely for anticholinergic effects and falls risk
   • Consider non-pharmacological approaches first

Important Considerations

• Avoid combining with other CNS depressants including alcohol, which may enhance performance impairment 4
• Morning drowsiness: May persist due to hydroxyzine's prolonged half-life 4
• Paradoxical stimulation: Can occasionally occur, particularly in children 4
• Monitoring: Assess effectiveness and side effects within 2-4 weeks of initiating treatment 6

Hydroxyzine provides a non-benzodiazepine option for managing nighttime anxiety with the added benefit of sedation for sleep, though clinicians should be mindful of potential next-day impairment and anticholinergic effects, particularly in older adults.