What is the recommended dose of hydroxyzine (prn) for an adult with cardiac impairment experiencing anxiety?

Hydroxyzine Dosing for Adults with Cardiac Impairment and Anxiety

For adults with cardiac impairment experiencing anxiety, the recommended starting dose of hydroxyzine should be reduced to 25 mg three times daily as needed, with careful monitoring for cardiovascular effects. 1

Dosing Recommendations

• The standard FDA-approved dose for anxiety in adults is 50-100 mg four times daily 1, but this should be reduced in patients with cardiac impairment
• For adults with cardiac impairment, start with 25 mg three times daily as needed 1, 2
• Titrate cautiously based on response and tolerability, not exceeding 50 mg three times daily in cardiac impairment 1, 2
• Use the lowest effective dose to minimize cardiac risk 2

Cardiac Considerations

• Hydroxyzine may produce abnormal ventricular repolarization when given in substantial doses or to susceptible individuals 2
• Risk of QT interval prolongation is increased in patients with cardiac impairment 2
• Avoid combining with other medications that can prolong QT interval, such as:
  • Phenothiazines (especially thioridazine) 2
  • Tricyclic antidepressants 2
  • Class I antiarrhythmics (quinidine, procainamide) 2
  • Other QT-prolonging medications 2

Monitoring Recommendations

• Perform baseline ECG before initiating treatment 2
• Monitor for symptoms of cardiac adverse effects:
  • Palpitations 2
  • Dizziness 3
  • Syncope 3
• Consider periodic ECG monitoring, especially when increasing doses 2
• Monitor for excessive sedation, which may mask cardiac symptoms 4

Alternative Options to Consider

• If cardiac risk is significant, consider non-sedating anxiolytics with less cardiac impact 3
• Buspirone may be a safer alternative for patients with significant cardiac impairment 5
• For severe anxiety requiring immediate control, lorazepam at reduced doses (0.5-1 mg) may be considered with careful monitoring 3

Common Side Effects

• Drowsiness/sedation (most common side effect, reported in 28% vs 14% with placebo) 6
• Dry mouth (14% vs 5% with placebo) 6
• Dizziness 3
• Weight gain (12% vs 10% with placebo) 6

Efficacy Considerations

• Hydroxyzine has demonstrated efficacy for generalized anxiety disorder in multiple clinical trials 5, 6, 4
• Onset of anxiolytic effect typically begins within the first week of treatment 6
• Efficacy is maintained throughout treatment periods and after discontinuation without rebound anxiety 6, 4

Important Precautions

• Sedation tends to be most pronounced during the first week of treatment and may diminish over time 6
• Avoid abrupt discontinuation; although withdrawal symptoms are uncommon, gradual tapering is preferred in cardiac patients 4
• Advise patients to avoid alcohol and other CNS depressants which may potentiate cardiac and sedative effects 3
• Elderly patients with cardiac impairment may be more susceptible to adverse effects and should start at even lower doses (12.5-25 mg) 3