What is the recommended dose of Atarax (hydroxyzine) for treating pruritus?

Recommended Dosage of Hydroxyzine (Atarax) for Pruritus

For the treatment of pruritus, hydroxyzine (Atarax) should be administered at a dose of 25 mg three to four times daily for adults. 1

Dosage Guidelines by Age

• Adults: 25 mg three to four times daily (75-100 mg total daily dose) 1
• Children over 6 years: 50-100 mg daily in divided doses 1
• Children under 6 years: 50 mg daily in divided doses 1

Treatment Approach Based on Severity

Mild to Moderate Pruritus

• First-line: Topical treatments (moderate/high-potency steroids) 2
• Second-line: Oral antihistamines, including hydroxyzine 25-50 mg daily 2

Moderate to Severe Pruritus

• For intense or widespread pruritus limiting instrumental activities of daily living:
  • Continue with topical moderate/high-potency steroids
  • Add oral antihistamines (hydroxyzine 25-50 mg daily) 2
  • Consider GABA agonists (pregabalin/gabapentin) for refractory cases 2

Severe or Intolerable Pruritus

• Interrupt causative treatment if applicable
• Continue topical steroids
• Use oral antihistamines (hydroxyzine 25-50 mg daily) 2
• Consider GABA agonists for refractory cases 2

Clinical Considerations

Timing of Administration

• First-generation antihistamines like hydroxyzine are particularly useful for nighttime dosing due to their sedative properties 2
• For daytime use, consider non-sedating second-generation antihistamines (loratadine 10 mg daily) 2

Duration of Treatment

• Reassess after 2 weeks of treatment 2
• If symptoms worsen or do not improve, consider alternative treatments or specialist referral

Important Precautions

• Sedation is a common side effect and may limit daytime use 2
• Long-term use of sedative antihistamines should be avoided except in palliative settings due to potential risk of cognitive effects 2
• Adjust dosage according to individual patient response 1

Alternative Treatments

• For patients who cannot tolerate hydroxyzine:
  • Non-sedating antihistamines (loratadine 10 mg, fexofenadine 180 mg) 2
  • Gabapentin (900-3600 mg daily) or pregabalin (25-150 mg daily) 2
  • Combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) 2

Comparative Efficacy

• A randomized trial comparing hydroxyzine 25 mg daily with doxepin 10 mg daily and cetirizine 10 mg daily found that hydroxyzine was more effective than cetirizine in controlling pruritus symptoms 3
• Another study showed that both hydroxyzine and gabapentin significantly improved pruritus in dialysis patients, with no significant difference between the two treatments 4

Hydroxyzine remains an effective option for managing pruritus, particularly when sedation is not a concern or when nighttime symptoms predominate. The dosage should be adjusted based on clinical response and tolerability.