Hydroxyzine Dosing for Panic Attacks
For acute panic attacks, hydroxyzine 50-100 mg orally is the recommended dose for adults, with effects beginning in 15-30 minutes and lasting 4-6 hours. 1, 2, 3
Standard Dosing Protocol
For symptomatic relief of acute anxiety and panic:
- Adults: 50-100 mg orally, which can be repeated every 4-6 hours as needed (maximum 400 mg daily in divided doses) 3
- Elderly or sensitive patients: Start with 25 mg to minimize sedative and anticholinergic effects 1, 2
- Onset of action: 15-30 minutes after oral administration 1, 2
- Duration of effect: 4-6 hours 1, 2
Clinical Application Strategy
Hydroxyzine works through H1-receptor antagonism and provides anxiolytic effects particularly useful for somatic symptoms of panic (trembling, physical tension). 1 The anticholinergic properties may offer better control of physical anxiety manifestations compared to second-generation antihistamines. 1, 2
For patients with panic attacks plus insomnia: Administer 50-100 mg at bedtime to address both conditions simultaneously. 1, 2
Important Limitations and Caveats
Hydroxyzine is NOT a first-line treatment for panic disorder. The evidence base for hydroxyzine specifically in panic disorder is extremely limited—the provided studies focus on generalized anxiety disorder, not panic attacks. 4, 5 High-potency benzodiazepines (alprazolam, clonazepam) and SSRIs remain the FDA-approved and guideline-recommended treatments for panic disorder. 6
The Cochrane review found only modest evidence for hydroxyzine even in GAD, with high risk of bias in available studies. 4 While hydroxyzine showed superiority over placebo at 50 mg daily in GAD trials, the review concluded it cannot be recommended as a reliable first-line treatment due to methodological limitations. 4, 5
Contraindications and Precautions
Avoid or use extreme caution in:
- Closed-angle glaucoma 1, 2
- Prostatic hypertrophy 1, 2
- Elderly patients (increased anticholinergic sensitivity) 1, 2
- Cognitive impairment 1
- Early pregnancy (contraindicated per UK guidelines) 2
- Severe liver or renal disease 2
Primary adverse effect: Sedation/drowsiness is common and may be more pronounced than with other anxiolytics. 4, 5
Clinical Reality Check
In real-world practice, hydroxyzine serves best as an adjunctive or temporary measure rather than definitive panic disorder treatment. For established panic disorder requiring ongoing management, SSRIs (like paroxetine) or high-potency benzodiazepines with proven efficacy should be prioritized. 7, 6 Hydroxyzine may be reasonable for occasional situational anxiety or as a non-addictive alternative when benzodiazepines are contraindicated, but expectations should be tempered given the limited evidence base for panic-specific indications.