What is the preferred treatment for flight anxiety, benzodiazepines (BZD) or hydroxyzine (antihistamine)?

Benzodiazepines versus Hydroxyzine for Flight Anxiety

Hydroxyzine is preferred over benzodiazepines for flight anxiety due to its better safety profile, lack of dependency risk, and absence of rebound effects that can worsen anxiety with subsequent exposures.

Comparison of Medication Options

Benzodiazepines

• Mechanism: Act as GABA receptor agonists, decreasing neuronal excitability 1
• Efficacy: Provide immediate anxiety reduction during flights 2
• Major concerns:
  • Regular use can lead to tolerance, addiction, and cognitive impairment 1
  • Paradoxical agitation occurs in approximately 10% of patients 1
  • Can hinder therapeutic effects of exposure therapy, potentially worsening anxiety on subsequent flights 2
  • Research shows alprazolam may actually increase physiological activation under acute stress and lead to more anxiety and panic attacks during subsequent exposures 2
  • Risk of dependency even with short-term use at recommended doses 3
  • Potential for severe withdrawal symptoms including seizures if discontinued abruptly 3

Hydroxyzine

• Mechanism: Antihistamine with sedative and anxiolytic effects 1
• Efficacy: More effective than placebo for generalized anxiety disorder 4
• Advantages:
  • No risk of dependency or withdrawal 4
  • Approved for anxiolytic use in both Europe and the United States 1
  • Available in tablet and syrup forms with few contraindications in children (suggesting good safety profile) 1
  • Does not impair exposure therapy benefits for future flights 4, 5
  • Lacks the rebound anxiety seen with benzodiazepines 4

Clinical Decision Algorithm

1. First-line treatment: Hydroxyzine

   • Typical dosing: 25-50mg taken 1-2 hours before flight
   • May repeat dose during longer flights if needed
   • Benefits: Effective anxiolysis without dependency risk or interference with natural habituation

2. Consider benzodiazepines only if:

   • Patient has previously failed hydroxyzine trial
   • Patient has no history of substance use disorders
   • Flight is a one-time occurrence with no anticipated future flights
   • Use lowest effective dose of short-acting agent (e.g., lorazepam 0.5-1mg)

3. Contraindications to consider:

   • For hydroxyzine: QT prolongation risk, severe sedation in elderly 6
   • For benzodiazepines: History of substance abuse, concurrent use of other CNS depressants, need for alertness during/after flight 3

Important Clinical Considerations

• Avoid concurrent use of benzodiazepines with other CNS depressants including alcohol during flights, as this increases risk of respiratory depression 1

• Hydroxyzine precautions:

  • Can cause QT prolongation in patients with risk factors 6
  • May cause excessive sedation, especially in elderly patients 6
  • Potentiating action when used with other CNS depressants 6

• Benzodiazepine risks:

  • Research shows alprazolam actually increased heart rate and respiratory rate during flights despite subjective anxiety reduction 2
  • More concerning, patients using alprazolam showed substantial increase in panic attacks (7% to 71%) on subsequent flights 2

• Non-pharmacological options should be considered alongside medication:

  • Cognitive behavioral therapy techniques
  • Relaxation strategies
  • Distraction techniques during flight 1

By choosing hydroxyzine over benzodiazepines for flight anxiety, you prioritize both immediate symptom relief and long-term outcomes, avoiding the potential for dependency and paradoxical worsening of flight anxiety with repeated exposures.