Can Atarax (hydroxyzine) help with sleep?

Hydroxyzine (Atarax) for Sleep: Efficacy and Considerations

Hydroxyzine (Atarax) can help with sleep due to its sedating antihistamine properties, but it is not FDA-approved specifically for insomnia and should be used cautiously due to potential side effects including daytime drowsiness and cognitive impairment.

Efficacy for Sleep

• Hydroxyzine is a first-generation antihistamine with sedative properties that can be used off-label for sleep, though its efficacy for insomnia is not well established, especially for long-term use 1
• First-generation antihistamines like hydroxyzine are commonly used as self-remedies for insomnia, but evidence for their efficacy and safety is very limited 1
• In a randomized controlled trial, hydroxyzine 25mg at bedtime improved sleep behavior both subjectively and objectively (using wrist actigraphy) in patients with cirrhosis and minimal hepatic encephalopathy 2

Side Effects and Concerns

• First-generation antihistamines like hydroxyzine have significant potential to cause sedation, performance impairment, and anticholinergic effects 1
• Hydroxyzine can cause daytime drowsiness and cognitive impairment that may persist into the following day, with studies showing impaired performance on psychomotor and attention tests 3, 4
• Morning doses of hydroxyzine actually cause more pronounced cognitive impairment than evening doses, suggesting that the sedative effects can persist well into the next day 3
• Patients may not be aware of their sleepiness and slower reaction times when taking hydroxyzine, making it potentially dangerous for activities requiring alertness 4

Precautions and Contraindications

• Hydroxyzine has potentiating action when used with other central nervous system depressants such as narcotics, non-narcotic analgesics, and barbiturates, requiring dosage adjustments of these medications 5
• Hydroxyzine should be used with caution in patients with risk factors for QT prolongation, as cases of QT prolongation and Torsade de Pointes have been reported 5
• Elderly patients are more sensitive to the psychomotor impairment caused by hydroxyzine and are at increased risk for complications such as falls 1, 5
• Caution is advised if signs/symptoms of depression, compromised respiratory function, or hepatic heart failure are present 1

Alternative Options for Insomnia

• FDA-approved medications for insomnia include benzodiazepine receptor agonists (BzRAs) like zolpidem, eszopiclone, and zaleplon, as well as the melatonin receptor agonist ramelteon 1
• Non-pharmacological approaches such as cognitive behavioral therapy for insomnia (CBT-I) are recommended as first-line treatment for chronic insomnia 1, 6
• If medication is needed, short/intermediate-acting BzRAs or ramelteon are generally recommended as first-line pharmacological treatment for insomnia 1

Bottom Line

• While hydroxyzine may help with sleep due to its sedative properties, it is not FDA-approved for insomnia and carries risks of daytime sedation and cognitive impairment 5
• A study comparing levocetirizine (a non-sedating antihistamine) plus hydroxyzine at night versus levocetirizine alone found that adding hydroxyzine at night did not improve sleep or treatment efficacy but did increase daytime somnolence 7
• For patients requiring pharmacological treatment for insomnia, FDA-approved medications like short-acting BzRAs or ramelteon are generally preferred over off-label use of sedating antihistamines 1