Can hydroxyzine be used for anxiety in older adults tapering off lorazepam (Ativan)?

Hydroxyzine for Anxiety in Older Adults Tapering Off Lorazepam

Hydroxyzine is not recommended as a substitute for lorazepam in older adults due to its anticholinergic properties, sedative effects, and risk of QT prolongation, which can increase fall risk and cognitive impairment in this population. 1, 2

Safety Concerns with Hydroxyzine in Older Adults

• Hydroxyzine carries significant risks in elderly patients including sedation, confusion, and over-sedation; the FDA specifically notes that "elderly patients generally should be started on low doses of hydroxyzine and observed closely" 1
• Hydroxyzine has anticholinergic properties that can worsen cognitive function in older adults 2
• QT prolongation and Torsade de Pointes have been reported with hydroxyzine use, which is particularly concerning in older adults who may have underlying cardiac conditions 1
• The potentiating action of hydroxyzine with other CNS depressants (like recently used benzodiazepines) increases risk of excessive sedation 1

Alternative Approaches for Benzodiazepine Tapering

Non-Pharmacological Approaches (First-Line)

• Cognitive-behavioral therapy, problem-solving therapy, and supportive psychotherapy have demonstrated effectiveness for anxiety management during benzodiazepine tapering 2
• Integrative strategies such as relaxation techniques, massage therapy, and music therapy can help manage anxiety symptoms during tapering 2

Tapering Strategy

• Gradual tapering of lorazepam is strongly preferred over abrupt discontinuation to minimize withdrawal symptoms 2, 3
• The EMPOWER trial demonstrated success with gradual tapering over many weeks, with 27% of patients successfully stopping benzodiazepines compared to 5% in the control group 2
• A more gradual approach than the standard 25% weekly reduction is often needed in elderly patients 2

Pharmacological Alternatives If Needed

• Buspirone may be considered as it has shown efficacy in generalized anxiety disorder with a better safety profile in older adults compared to hydroxyzine 4
• SNRIs such as duloxetine can be considered for anxiety management with better safety profiles than hydroxyzine in older adults 2
• If short-term medication is absolutely necessary during acute withdrawal symptoms, lorazepam at reduced doses (0.25-0.5 mg) may be safer than introducing a new medication with different risks 2

Monitoring During Tapering

• Regular assessment for withdrawal symptoms including rebound anxiety, insomnia, and irritability 3
• Monitoring for cognitive function, fall risk, and orthostatic hypotension 2
• Evaluation of sleep quality, as sleep disturbance is a common withdrawal symptom 2

Special Considerations

• While hydroxyzine has shown some efficacy in managing benzodiazepine withdrawal symptoms in younger adults 3, the risks outweigh the benefits in older adults
• The Beers Criteria specifically identifies medications with anticholinergic properties (like hydroxyzine) as potentially inappropriate in older adults 2
• Older adults are particularly vulnerable to the sedating effects of hydroxyzine, which significantly increases fall risk 1, 2

Conclusion

While hydroxyzine has demonstrated efficacy for anxiety in general populations 5, 6, its risk profile makes it unsuitable for older adults tapering off benzodiazepines. The focus should be on gradual tapering of lorazepam combined with non-pharmacological interventions, with consideration of safer pharmacological alternatives only if absolutely necessary.