What is the preferred anxiolytic for a dialysis patient, Buspar (buspirone) or hydroxyzine?

Hydroxyzine is Preferred Over Buspirone for Anxiety in Dialysis Patients

For dialysis patients with anxiety, hydroxyzine 25mg is preferred over buspirone due to its more favorable pharmacokinetic profile in renal impairment and lack of need for dose adjustment in dialysis patients. 1

Pharmacokinetic Considerations in Dialysis Patients

Hydroxyzine

• Does not require dose adjustment in renal failure 1
• Can be used for acute or situational anxiety
• Provides relatively rapid onset of action compared to buspirone
• Has been shown to be effective for generalized anxiety disorder compared to placebo 2

Buspirone

• Requires dose reduction of 25-50% in anuric patients 3
• Higher concentrations of the active metabolite 1-PP are attained in anuric patients 3
• Has a delayed onset of action (2-4 weeks to become effective) 4
• Initial dosage typically starts at 5mg twice daily, with maximum dosage of 20mg three times daily 4
• Only useful in patients with mild to moderate agitation 4

Efficacy Considerations

Hydroxyzine has demonstrated efficacy comparable to benzodiazepines and buspirone in treating generalized anxiety disorder 2. While buspirone is effective for anxiety, it has several limitations in the dialysis population:

• Delayed onset of action (2-4 weeks) makes it unsuitable for acute anxiety 4
• Requires careful dose adjustment in renal impairment 3
• Pharmacokinetics are altered in renal failure with accumulation of active metabolites 3

Side Effect Profile

Hydroxyzine

• Main side effect is sedation/drowsiness 2
• This sedative effect may be beneficial for dialysis patients with anxiety and sleep disturbances
• Does not cause dependence or withdrawal symptoms

Buspirone

• Less sedating than hydroxyzine 5, 6
• No dependence or withdrawal issues 6
• However, altered metabolism in renal failure may increase risk of adverse effects 3

Clinical Application

When treating anxiety in dialysis patients:

1. Start with hydroxyzine 25mg as needed for anxiety symptoms
2. Monitor for excessive sedation and adjust timing of administration (e.g., at bedtime if sedation is problematic)
3. If hydroxyzine is ineffective or poorly tolerated, consider buspirone with appropriate dose reduction (starting at 2.5mg twice daily and titrating slowly)

Important Caveats

• Sedation from hydroxyzine may be problematic for some patients, particularly those who need to maintain alertness during the day
• For patients with chronic anxiety requiring long-term treatment, non-pharmacological approaches should be considered alongside medication 1
• Cognitive behavioral therapy, regular aerobic exercise, and mindfulness practices have demonstrated efficacy in reducing anxiety and depression in dialysis patients 1

Monitoring Recommendations

• Assess response to hydroxyzine after initial doses
• Monitor for excessive sedation or paradoxical excitation
• Evaluate need for continued therapy regularly
• Consider timing of administration relative to dialysis sessions (hydroxyzine can be given regardless of dialysis timing)

The American Heart Association and Kidney International guidelines support using medications that don't require significant dose adjustments in renal failure, making hydroxyzine a more practical choice than buspirone for most dialysis patients with anxiety 1.