Is it safe to prescribe hydroxyzine (antihistamine) three times daily to a geriatric patient for anxiety?

Hydroxyzine Three Times Daily Is Not Safe for Geriatric Patients with Anxiety

Hydroxyzine should not be prescribed three times daily for geriatric patients with anxiety due to significant risks of sedation, cognitive impairment, anticholinergic effects, and potential QT prolongation. 1 Instead, safer alternatives such as SSRIs, SNRIs, or low-dose benzodiazepines should be considered.

Risks of Hydroxyzine in Geriatric Patients

• Elderly patients are especially sensitive to the sedative effects of hydroxyzine, which can cause confusion and oversedation; geriatric patients should generally be started on low doses and observed closely if hydroxyzine must be used 1
• The FDA label specifically warns that hydroxyzine has potentiating action when used with other CNS depressants and can cause significant drowsiness, affecting driving ability and operation of machinery 1
• Hydroxyzine can cause QT prolongation and Torsade de Pointes, particularly concerning in elderly patients who often have pre-existing heart conditions or are on multiple medications 1
• First-generation antihistamines like hydroxyzine have significant anticholinergic effects that can cause dry mouth, constipation, urinary retention, and increased risk of narrow-angle glaucoma - all particularly problematic in the elderly 2

Preferred Alternatives for Anxiety in Geriatric Patients

• Antidepressants, particularly SSRIs and SNRIs with favorable pharmacokinetic profiles, are considered first-line treatment for anxiety disorders in the elderly 3
• For acute anxiety management in geriatric patients who can swallow, lorazepam 0.25-0.5mg (reduced dose for elderly) up to four times daily as needed (maximum 2mg in 24 hours) is recommended 2
• Buspirone may be beneficial for mild to moderate anxiety in geriatric patients, starting at 5mg twice daily (maximum 20mg three times daily), though it may take 2-4 weeks to become effective 2
• Mirtazapine and vortioxetine are also considered safe treatment options for anxiety in the elderly 3

Specific Concerns with Three-Times-Daily Dosing

• Multiple daily doses of hydroxyzine in elderly patients increase the risk of cumulative sedation and cognitive impairment 2
• First-generation antihistamines like hydroxyzine have prolonged plasma half-lives, and their end-organ effects persist longer than plasma levels, making multiple daily dosing particularly risky in the elderly 2
• Elderly patients taking hydroxyzine three times daily are at higher risk for falls, fractures, and subdural hematomas due to increased sedation 2

Monitoring and Precautions if Hydroxyzine Must Be Used

• If hydroxyzine must be used in a geriatric patient, start at the lowest possible dose and titrate slowly while monitoring for adverse effects 1
• Avoid concomitant use with other medications known to prolong QT interval (certain antipsychotics, antidepressants, antibiotics) 1
• Be aware of potential drug interactions, particularly with other CNS depressants, which would require dose reduction of the concomitant medication 1
• Monitor for signs of cognitive impairment, excessive sedation, urinary retention, constipation, and dry mouth 2

Evidence on Hydroxyzine for Anxiety

• While hydroxyzine has shown efficacy for generalized anxiety disorder in some studies at a fixed dose of 50mg, these studies were not specifically conducted in geriatric populations 4, 5, 6
• The most common side effect reported in hydroxyzine studies was sleepiness/drowsiness (28% vs 14% with placebo), which would be more problematic in elderly patients 6
• A Cochrane review concluded that despite being more effective than placebo for GAD, hydroxyzine cannot be recommended as a reliable first-line treatment due to high risk of bias in studies, small number of studies, and small sample sizes 5