Hydroxyzine Dosing for Anxiety

For adults with anxiety, hydroxyzine should be dosed at 50 to 100 mg four times daily as needed. 1

Adult Dosing Recommendations

For symptomatic relief of anxiety and tension associated with psychoneurosis, the FDA-approved dosage is 50 to 100 mg four times daily as needed 1
Lower starting doses (25 mg) may be appropriate for elderly patients or those sensitive to sedative effects 2
Onset of action is relatively rapid at approximately 15-30 minutes, with effects lasting 4-6 hours 2
For patients with comorbid anxiety and insomnia, administering a higher dose (50-100 mg) at bedtime may provide dual benefits 2

For elderly patients or those with increased sensitivity to sedative medications, start with a lower dose of 25 mg and titrate up as needed 2
For patients with panic disorder who also experience insomnia, a higher bedtime dose (50-100 mg) may be particularly beneficial 2
Dosage should be adjusted according to the patient's response to therapy 1

Hydroxyzine is a first-generation antihistamine with anxiolytic properties that works primarily through H1-receptor antagonism 2
Clinical trials have demonstrated efficacy of hydroxyzine at a fixed dose of 50 mg in generalized anxiety disorder, with superiority over placebo from the first week of treatment 3
In controlled studies, hydroxyzine 50 mg/day produced statistically and clinically significant anxiolytic effects maintained throughout 4 weeks of treatment 4

The most common side effect is transient sleepiness/drowsiness, reported in approximately 28% of patients (vs 14% with placebo) 4
Sleepiness typically appears during the first week of treatment and progressively diminishes with continued use 4
Other reported side effects include dry mouth (14%), weight gain (12%), and loss of concentration (9%) 4
Use with caution in patients with:
- Closed-angle glaucoma 2
- Prostatic hypertrophy 2
- Cognitive impairment 2
- Elderly patients (who are more susceptible to anticholinergic effects) 2

While hydroxyzine has demonstrated efficacy superior to placebo in treating anxiety, a Cochrane review noted limitations in the available evidence due to small sample sizes and potential bias in studies 5
Despite these limitations, clinical experience and available evidence support hydroxyzine as an effective non-benzodiazepine option for anxiety management 3

For patients concerned about the sedative effects of hydroxyzine, alternative non-benzodiazepine options like saffron may be considered, which carries less risk of tolerance, addiction, and cognitive impairment 6
Unlike benzodiazepines, which can cause paradoxical agitation in approximately 10% of patients, hydroxyzine has not been associated with this adverse effect 6