What is the recommended dose of hydroxyzine (an antihistamine) for anxiety and panic?

Hydroxyzine Dosing for Anxiety and Panic

For adults with anxiety and panic, hydroxyzine should be administered at 50-100 mg four times daily as needed, with lower doses (25-50 mg) initially recommended for elderly patients or those sensitive to sedation. 1

Adult Dosing Guidelines

The FDA-approved dosing for hydroxyzine in anxiety management is:

• Standard adult dose: 50-100 mg four times daily 1
• Initial dose for sensitive patients: Consider starting at 25 mg three to four times daily
• Maximum daily dose: 400 mg per day
• Administration: Can be taken as needed for acute anxiety/panic episodes

Pediatric Dosing

For children requiring anxiety management:

• Children under 6 years: 50 mg total daily dose, divided throughout the day 1
• Children over 6 years: 50-100 mg total daily dose, divided throughout the day 1

Clinical Efficacy

Hydroxyzine has demonstrated efficacy for generalized anxiety disorder in controlled trials:

• More effective than placebo in reducing anxiety symptoms 2
• Equivalent efficacy to benzodiazepines and buspirone in comparative studies 2
• Shows early effect on cognitive symptoms of anxiety 3

Administration Considerations

• Onset of action: Effects typically begin within 15-30 minutes of oral administration
• Duration: Effects generally last 4-6 hours per dose
• Timing: Can be used as needed for acute anxiety/panic episodes rather than scheduled dosing
• Tolerance: Unlike benzodiazepines, hydroxyzine does not develop dependence or tolerance 2

Advantages Over Other Anxiolytics

• Non-habit forming with absence of dependency 3
• No rebound anxiety upon discontinuation
• Can be safely discontinued without tapering
• Lacks abuse potential compared to benzodiazepines

Potential Side Effects and Monitoring

• Common side effects: Sedation/drowsiness (more common than with other anxiolytics) 2
• Monitoring needed: Level of sedation, cognitive function, anticholinergic effects
• Cautions:
  • Avoid in patients with severe respiratory depression 4
  • Use with caution in elderly patients due to increased risk of sedation
  • May cause excessive daytime sleepiness at higher doses 5

Clinical Pearls

• Hydroxyzine can be particularly useful for patients with comorbid anxiety and pruritus/allergic conditions
• Consider lower initial doses (25 mg) in elderly patients or those sensitive to sedation
• The sedative properties can be beneficial for patients with anxiety-related sleep disturbances
• Unlike benzodiazepines, hydroxyzine can be safely used in patients with a history of substance abuse

Hydroxyzine provides an effective non-benzodiazepine option for anxiety management with minimal risk of dependence or tolerance, making it suitable for both acute and chronic anxiety management.