Hydroxyzine Dosing for Anxiety
For adults with anxiety, hydroxyzine is recommended at 50-100 mg four times daily (total daily dose of 200-400 mg). 1
Dosing Guidelines
The FDA-approved dosing for hydroxyzine in anxiety management is clearly established:
- Adults: 50-100 mg four times daily
- Children over 6 years: 50-100 mg daily in divided doses
- Children under 6 years: 50 mg daily in divided doses
Clinical Evidence and Efficacy
Hydroxyzine has demonstrated efficacy for generalized anxiety disorder (GAD) in clinical trials. Studies have shown that hydroxyzine at a fixed dose of 50 mg daily is superior to placebo in reducing anxiety symptoms, with benefits observed from the first week of treatment 2. A randomized controlled trial showed that hydroxyzine was more effective than placebo for GAD with an odds ratio of 0.30 (95% CI 0.15 to 0.58) 3.
In a double-blind study, hydroxyzine at 50 mg/day produced statistically significant anxiolytic effects compared to placebo, with benefits maintained throughout the 4-week treatment period 4. The anxiolytic effect persisted even after abrupt discontinuation, without rebound anxiety or withdrawal symptoms.
Administration Considerations
- Start with the recommended dose based on age
- Adjust dosing according to individual response
- Doses can be divided throughout the day to maintain therapeutic effect
- When used as a premedication for sedation, 50-100 mg is recommended for adults
Side Effects and Monitoring
The most common side effect of hydroxyzine is transient sleepiness or drowsiness, which typically appears during the first week of treatment and gradually diminishes with continued use 4. In clinical trials, sleepiness was reported in 28% of patients taking hydroxyzine versus 14% with placebo 4.
Other potential side effects include:
- Dry mouth (14% vs 5% with placebo)
- Weight gain (12% vs 10%)
- Loss of concentration (9% vs 8%)
- Insomnia (9% vs 6%)
Special Populations
Elderly Patients
While the FDA label doesn't specify different dosing for elderly patients, clinical practice suggests starting at lower doses in this population due to increased sensitivity to side effects. Elderly patients are more susceptible to sedation and anticholinergic effects.
Patients with Cognitive Impairment
Caution is advised in patients with cognitive impairment as antihistamines like hydroxyzine may potentially worsen cognitive function 5.
Clinical Pearls
- Hydroxyzine's anxiolytic effects typically begin within the first week of treatment
- Unlike benzodiazepines, hydroxyzine does not cause dependency or withdrawal symptoms
- Hydroxyzine can be used as an adjunctive treatment during benzodiazepine withdrawal 6
- The medication can be used both for short-term anxiety relief and longer-term management
- Sedative effects may be beneficial for patients with anxiety-related sleep disturbances
By following these dosing guidelines, hydroxyzine can be an effective option for managing anxiety symptoms while avoiding the dependency issues associated with benzodiazepines.