Can a patient with impaired renal function (dialysis patient) use Atarax (hydroxyzine)?

Use of Hydroxyzine (Atarax) in Dialysis Patients

Hydroxyzine can be used in dialysis patients but requires dose adjustment and careful monitoring due to its potential for accumulation in renal failure.

Pharmacokinetics in Renal Failure

Hydroxyzine, like many medications, requires special consideration in patients with impaired renal function. While specific guidelines for hydroxyzine in dialysis patients are limited in the available evidence, we can make recommendations based on general principles of drug management in renal failure.

Dose Adjustment Considerations

• Medications in patients with renal failure often require dose adjustments to prevent accumulation and toxicity
• Hydroxyzine is metabolized primarily by the liver, but its metabolites are excreted through the kidneys
• In renal failure, these metabolites can accumulate, potentially leading to increased side effects

Evidence for Hydroxyzine Use in Dialysis

A 2020 randomized crossover clinical trial specifically evaluated hydroxyzine in dialysis patients with pruritus 1. This study found:

• Hydroxyzine at 25 mg/day was effective in treating pruritus in dialysis patients
• No significant safety concerns were reported at this reduced dosage
• The efficacy was comparable to gabapentin (another medication used for pruritus in dialysis)

Recommended Approach

1. Start with a reduced dose: Begin with 25 mg/day as supported by clinical evidence 1
2. Monitor for side effects: Particularly CNS effects such as sedation, confusion, or lethargy
3. Administer after dialysis: To prevent premature removal of the drug
4. Avoid in patients with severe hepatic dysfunction: As hydroxyzine is primarily metabolized by the liver

Potential Side Effects to Monitor

• Increased sedation
• Confusion
• Prolonged QT interval (especially if combined with other QT-prolonging medications)
• Anticholinergic effects (dry mouth, blurred vision, urinary retention)

Alternative Options

If hydroxyzine is not tolerated or contraindicated, consider:

• Gabapentin (with appropriate dose adjustment for dialysis patients) 1
• Non-pharmacological approaches for symptom management
• Consultation with a nephrologist for medication review

Important Considerations

While specific guidelines for hydroxyzine in dialysis patients are limited, the general principles of medication management in renal failure apply. The K/DOQI clinical practice guidelines emphasize that many medications require careful consideration in dialysis patients 2, with dose adjustments or alternative medications often necessary.

Similar to other medications used in dialysis patients, hydroxyzine should be used with caution, starting at a lower dose and monitoring closely for adverse effects. The clinical trial evidence suggests that at appropriate doses, hydroxyzine can be effective and relatively safe in this population 1.