What is the typical dosage of Vistaril (hydroxyzine) for anxiety and what are the alternative treatments?

Hydroxyzine (Vistaril) Dosage for Anxiety and Alternative Treatments

For anxiety, the typical dosage of hydroxyzine is 50 to 100 mg four times daily for adults, with treatment individualized according to patient response. 1

Hydroxyzine Dosing Guidelines

• Adults with anxiety: 50-100 mg four times daily (200-400 mg total daily dose) 1
• Elderly patients or those with hepatic impairment may require lower doses
• Hydroxyzine can be used as needed for acute anxiety or on a scheduled basis
• Effects typically begin within 15-30 minutes after oral administration

Efficacy of Hydroxyzine for Anxiety

Hydroxyzine has demonstrated efficacy for generalized anxiety disorder:

• Superior to placebo in controlled clinical trials 2, 3
• Shows improvement in anxiety symptoms from the first week of treatment 3
• Particularly effective for the cognitive component of anxiety 3
• In a multicentre study, hydroxyzine showed significant improvement on the Hamilton Anxiety Scale compared to placebo (10.75 vs 7.23 points reduction) 2

However, a Cochrane review noted that while hydroxyzine is more effective than placebo for GAD, the high risk of bias in available studies and small sample sizes prevent recommending it as a reliable first-line treatment 4.

Common Side Effects

• Drowsiness/sedation (most common) 5
• Dry mouth
• Constipation
• Blurred vision
• Dizziness

The sedative effects often diminish with continued use at the same dosage level 5.

Alternative Treatments for Anxiety

First-Line Alternatives

1. SSRIs (Selective Serotonin Reuptake Inhibitors):

   • Sertraline: Starting dose 50 mg daily, which is the optimal dose for most patients 6
   • Citalopram, escitalopram, paroxetam, fluoxetine
   • Advantages: Effective for long-term management, non-habit forming

2. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

   • Venlafaxine, duloxetine
   • Useful for patients with comorbid pain conditions

3. Buspirone:

   • Non-benzodiazepine anxiolytic
   • Typical dosing: 5 mg three times daily initially, gradually increased
   • Less sedating than hydroxyzine but may take 2-3 weeks for full effect 2

Second-Line Alternatives

1. Benzodiazepines (for short-term or breakthrough anxiety):

   • Alprazolam: 0.5 mg orally, may repeat after 30-60 minutes if needed 7
   • Lorazepam: 0.5-1 mg orally/IV/IM; lower doses (0.25-0.5 mg) for elderly 7
   • Caution: Risk of dependence, tolerance, and withdrawal

2. Atypical Antipsychotics (primarily for elderly patients with agitation):

   • Risperidone: Starting at 0.25 mg/day (max 2 mg/day) 7
   • Olanzapine: Starting at 2.5 mg/day (max 10 mg/day) 7
   • Quetiapine: 12.5-25 mg twice daily 7

3. Mirtazapine:

   • Starting dose 7.5-15 mg/day for elderly patients 7
   • Beneficial for patients with comorbid insomnia or poor appetite

Clinical Decision Algorithm

1. For acute, intermittent anxiety:

   • Hydroxyzine 25-50 mg as needed
   • Alternative: Short-acting benzodiazepine (with caution)

2. For chronic anxiety:

   • First try: SSRI (e.g., sertraline 50 mg daily) or SNRI
   • If ineffective or not tolerated: Try buspirone or mirtazapine
   • For breakthrough anxiety while on SSRI/SNRI: Add hydroxyzine as needed

3. For elderly patients:

   • Start with lower doses of hydroxyzine (25 mg)
   • Consider mirtazapine (7.5-15 mg) as an alternative 7
   • Use benzodiazepines with extreme caution (lorazepam 0.25-0.5 mg if necessary) 7

Important Considerations

• Hydroxyzine should be avoided in patients with known QT prolongation
• Benzodiazepines should be avoided in patients with respiratory depression, acute narrow-angle glaucoma, or concurrent alcohol use 7
• Non-pharmacological interventions (CBT, relaxation techniques) should be considered alongside medication
• Monitor for excessive sedation, especially when initiating treatment