Is Atarax (hydroxyzine) safe with hypotension?

Atarax (Hydroxyzine) Should NOT Be Given with This Blood Pressure

Do not administer Atarax (hydroxyzine) to this patient with a blood pressure of 127/49 mmHg due to the significant diastolic hypotension (49 mmHg), as hydroxyzine can worsen hypotension and cause orthostatic hypotension, particularly dangerous when diastolic pressure is already critically low. 1, 2

Critical Blood Pressure Concerns

• The diastolic pressure of 49 mmHg represents severe hypotension that requires immediate evaluation before any sedating medication is considered 3
• While systolic BP of 127 mmHg appears normal, the pulse pressure of 78 mmHg (127-49) is abnormally wide and may indicate underlying cardiovascular pathology 3
• Hydroxyzine is specifically documented to cause orthostatic hypotension as a common adverse effect, which could precipitate cardiovascular collapse in a patient with pre-existing diastolic hypotension 2

Hydroxyzine-Specific Risks in Hypotension

Direct Cardiovascular Effects

• The FDA label explicitly warns that hydroxyzine overdose causes hypotension, and recommends controlling it with intravenous fluids and vasopressors (levarterenol or metaraminol) 1
• The FDA specifically contraindicates epinephrine use because hydroxyzine counteracts epinephrine's pressor action, limiting rescue options if blood pressure drops further 1
• First-generation antihistamines like hydroxyzine commonly cause dizziness and orthostatic hypotension even at therapeutic doses 2

Cardiac Conduction Risks

• Hydroxyzine can cause QT prolongation and Torsades de Pointes, particularly problematic in hemodynamically unstable patients 1, 4
• Abnormal ventricular repolarization may occur even at therapeutic doses in susceptible individuals 4
• ECG monitoring is recommended in cases of hydroxyzine overdose due to dysrhythmia risk 1

Alternative Management Strategy

Immediate Assessment Required

• Measure orthostatic vital signs (BP after 5 minutes supine, then at 1 and 3 minutes standing) to assess for orthostatic hypotension before any medication 5
• Investigate the cause of isolated diastolic hypotension (aortic regurgitation, severe anemia, hyperthyroidism, arteriovenous fistula) 5
• Assess for end-organ hypoperfusion despite normal systolic pressure (mental status, urine output, skin perfusion) 3

If Anxiolytic Treatment Is Necessary

• Consider second- or third-generation antihistamines (cetirizine, loratadine, fexofenadine) which have superior safety profiles and minimal cardiovascular effects compared to hydroxyzine 2
• These newer agents lack the sedation, orthostatic hypotension, and cardiac risks of first-generation antihistamines like hydroxyzine 2
• If sedation is specifically required, benzodiazepines may be safer than hydroxyzine in this hemodynamic context, though still requiring caution 6

Key Clinical Pitfalls to Avoid

• Do not dismiss isolated diastolic hypotension as benign—it requires investigation and may represent serious underlying pathology 5, 3
• Never assume normal systolic pressure means adequate perfusion—diastolic pressure is critical for coronary and organ perfusion 3
• Avoid all first-generation antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine) in patients with any degree of hypotension 2
• If hypotension worsens after hydroxyzine administration, do not use epinephrine as it will be ineffective; use norepinephrine or phenylephrine instead 1