From the Guidelines
Hydroxyzine (Atarax) overdose management is primarily supportive, with a focus on establishing an open airway and providing bag-mask ventilation, followed by endotracheal intubation when appropriate.
Key Considerations
- The use of flumazenil, a competitive antagonist at the benzodiazepine binding site on the GABA-A receptor, is not recommended for hydroxyzine overdose as it is not a benzodiazepine, but rather an antihistamine with sedative properties 1.
- Standard life support measures are crucial in managing patients with hydroxyzine overdose, including establishing an open airway, providing bag-mask ventilation, and endotracheal intubation when necessary 1.
- Naloxone administration should not be delayed if opioid overdose is suspected, as hydroxyzine overdose often involves multiple drugs 1.
- Monitoring for potential complications, such as respiratory depression, cardiac arrhythmias, and seizures, is essential in the management of hydroxyzine overdose.
Treatment Approach
- Supportive care is the mainstay of treatment, with a focus on maintaining adequate oxygenation, ventilation, and circulation.
- Activated charcoal may be considered if the patient presents early after ingestion, although its effectiveness in hydroxyzine overdose is not well established.
- Close monitoring of the patient's vital signs, cardiac rhythm, and respiratory status is crucial to promptly identify and manage any potential complications.
From the FDA Drug Label
The most common manifestation of hydroxyzine overdosage is hypersedation. Other reported signs and symptoms were convulsions, stupor, nausea and vomiting. As in the management of overdosage with any drug, it should be borne in mind that multiple agents may have been taken. If vomiting has not occurred spontaneously, it should be induced. Immediate gastric lavage is also recommended General supportive care, including frequent monitoring of the vital signs and close observation of the patient, is indicated. Hypotension, though unlikely, may be controlled with intravenous fluids and levarterenol or metaraminol. Do not use epinephrine as hydroxyzine counteracts its pressor action. Hydroxyzine overdose may cause QT prolongation and Torsade de Pointes ECG monitoring is recommended in cases of hydroxyzine overdose. There is no specific antidote. It is doubtful that hemodialysis would be of any value in the treatment of overdosage with hydroxyzine. However, if other agents such as barbiturates have been ingested concomitantly, hemodialysis may be indicated There is no practical method to quantitate hydroxyzine in body fluids or tissue after its ingestion or administration.
The management of hydroxyzine (Atarax) overdose includes:
- Induction of vomiting if it has not occurred spontaneously
- Immediate gastric lavage
- General supportive care, including:
- Frequent monitoring of vital signs
- Close observation of the patient
- Control of hypotension with intravenous fluids and levarterenol or metaraminol (avoid epinephrine)
- ECG monitoring to detect potential QT prolongation and Torsade de Pointes There is no specific antidote for hydroxyzine overdose 2
From the Research
Management of Hydroxyzine Overdose
The management of hydroxyzine overdose involves several key considerations, including:
- The risk of QT prolongation and torsade de pointes associated with hydroxyzine use, particularly in patients with underlying medical conditions or concomitant medications that constitute additional risk factors 3
- The importance of supportive treatment, as specific antidotes for drug overdose are not widely available 4
- The need to consider the pharmacological properties of hydroxyzine, including its antihistaminergic and anticholinergic effects, and its anti-arrhythmic potential 5
- The potential for severe intoxication in case of overdose, and the importance of prescribing the lowest possible amount of hydroxyzine 5
Treatment Options
Treatment options for hydroxyzine overdose may include:
- Observation alone, as the risk of treating the overdose with an additional pharmacological agent may outweigh the potential benefit 4
- Supportive treatment, based on the individual patient's needs 4
- Consideration of the patient's underlying medical conditions and concomitant medications, and the potential for delayed effects 4
Pharmacokinetics and Pharmacodynamics
The pharmacokinetics and pharmacodynamics of hydroxyzine have been studied in patients with primary biliary cirrhosis, and have shown that hydroxyzine elimination is impaired in these patients 6. This may have implications for the management of hydroxyzine overdose in patients with liver disease.