Can Atarax (hydroxyzine) cause hypotension?

Hydroxyzine (Atarax) and Blood Pressure Effects

Hydroxyzine can cause hypotension, particularly in overdose situations, but it is not commonly associated with significant blood pressure reduction at therapeutic doses. 1

Mechanism and Blood Pressure Effects

Hydroxyzine is an antihistamine medication with anxiolytic properties. Its effects on blood pressure include:

• In standard therapeutic doses, hydroxyzine is not typically associated with clinically significant hypotension
• Hypotension is specifically mentioned as a potential manifestation of hydroxyzine overdose in the FDA drug label 1
• When hypotension does occur with hydroxyzine overdose, it can be managed with intravenous fluids and vasopressors such as levarterenol or metaraminol 1
• Notably, epinephrine should NOT be used to treat hydroxyzine-induced hypotension, as hydroxyzine counteracts its pressor action 1

Clinical Considerations

Risk Factors for Hydroxyzine-Induced Hypotension

• Patients at higher risk for experiencing hypotension with hydroxyzine include:
  • Those taking other medications with hypotensive effects
  • Elderly patients
  • Patients with cardiovascular disease
  • Overdose situations

Monitoring Recommendations

• Blood pressure monitoring is advisable when:
  • Starting hydroxyzine in patients with cardiovascular disease
  • Using hydroxyzine with other medications that may lower blood pressure
  • Administering higher doses of hydroxyzine

Medication Interactions

• Caution should be exercised when combining hydroxyzine with:
  • Alpha-adrenergic blockers 2
  • Beta-blockers 2
  • Calcium channel blockers 2
  • ACE inhibitors or ARBs 2
  • Direct vasodilators like hydralazine 2
  • Other CNS depressants that may have additive effects

Evidence from Clinical Experience

While the primary concern with hydroxyzine is typically sedation rather than hypotension, there is some clinical evidence regarding its cardiovascular effects:

• A study of 55 patients with anxiety disorders, including some with cardiovascular conditions, found hydroxyzine to be well-tolerated even in patients with cardiovascular disorders 3

• Paradoxically, one study examining patients receiving peribulbar injections found that those premedicated with hydroxyzine actually experienced increases in systolic arterial pressure (up to 20% above baseline) rather than decreases 4

• A case report documented an anaphylactic reaction to hydroxyzine that included severe bronchospasm and hypotension, though this represents an allergic reaction rather than a direct pharmacological effect 5

Management of Hydroxyzine-Related Hypotension

If hypotension occurs:

1. Discontinue hydroxyzine
2. Position patient supine with legs elevated
3. Administer IV fluids
4. If needed, use vasopressors such as levarterenol or metaraminol
5. Do NOT use epinephrine as hydroxyzine counteracts its pressor effects 1
6. Monitor ECG as hydroxyzine overdose may cause QT prolongation 1

In conclusion, while hydroxyzine can cause hypotension, particularly in overdose situations, it is not commonly associated with significant blood pressure reduction at therapeutic doses in most patients.