Can Hydroxyzine Be Added to Lexapro 20mg for Anxiety After Buspar Failure?
Yes, hydroxyzine can be used as an adjunct anxiolytic in this patient increasing to escitalopram 20mg, particularly for short-term symptom relief while awaiting full SSRI response. 1
Rationale for Hydroxyzine Use
Hydroxyzine is FDA-approved for symptomatic relief of anxiety and tension associated with psychoneurosis and as an adjunct in organic disease states where anxiety is manifested. 1
The medication demonstrates efficacy superior to placebo across all anxiety measures, with benefits appearing as early as the first week of treatment at 50mg daily. 2, 3
Hydroxyzine provides a mechanistically distinct approach from the failed buspirone trial, working through H1 histaminergic receptor antagonism rather than 5-HT1A partial agonism. 4
Timing and Strategic Use
Hydroxyzine is particularly valuable during the 4-8 week period required for escitalopram to reach full therapeutic effect, as it provides rapid anxiolytic action while the SSRI dose is being optimized. 5
The combination allows management of potential early activation syndrome or increased anxiety that can occur when increasing escitalopram to 20mg, which typically manifests within the first few days to weeks. 6
Clinical trials demonstrate maintained efficacy throughout 4 weeks of treatment without rebound anxiety or withdrawal symptoms upon abrupt discontinuation. 2, 3
Dosing and Administration
Start with hydroxyzine 50mg daily, which has been validated in controlled trials for generalized anxiety disorder. 3
The medication can be dosed flexibly (once daily or divided doses) based on symptom patterns and tolerability. 1
Reassess the need for hydroxyzine after 4 months, as the FDA label notes that effectiveness as an antianxiety agent for long-term use beyond this period has not been systematically assessed. 1
Safety Profile and Monitoring
The most common side effect is transient sleepiness (28% vs 14% with placebo), which typically appears during the first week and progressively diminishes. 3
Other reported effects include dry mouth (14%), weight gain (12%), loss of concentration (9%), and insomnia (9%). 3
Hydroxyzine demonstrates an absence of dependency, lack of organ toxicity, and no interference with digitalis or other cardiac medications. 2
The medication may potentiate sedatives like meperidine and barbiturates, though this is less relevant in anxiety management. 1
Advantages Over Alternative Approaches
Hydroxyzine avoids the dependency, tolerance, and cognitive impairment risks associated with benzodiazepines, which affect approximately 10% of patients with paradoxical agitation. 7
Unlike benzodiazepines, hydroxyzine can be discontinued abruptly without withdrawal symptoms or rebound anxiety. 3
The medication provides faster cognitive improvement compared to lorazepam in controlled trials. 2
Important Caveats
While hydroxyzine shows efficacy, a Cochrane review noted high risk of bias in included studies and small sample sizes, preventing recommendation as a reliable first-line monotherapy. 8
The primary treatment strategy remains optimizing escitalopram to 20mg and allowing 8-12 weeks for full evaluation, with hydroxyzine serving as adjunctive symptomatic relief. 5
If anxiety persists after adequate escitalopram trial, consider switching to an SNRI like venlafaxine, which demonstrates superior efficacy in treatment-resistant cases. 5
Combining pharmacotherapy with cognitive-behavioral therapy provides greater efficacy than medication alone for anxiety disorders. 5, 9