Can a patient who has received Ativan (lorazepam) twice be given Atarax (hydroxyzine)?

Can Atarax (Hydroxyzine) Be Given After Two Doses of Ativan (Lorazepam)?

Yes, Atarax (hydroxyzine) can be safely administered to a patient who has received Ativan (lorazepam) twice, but the combination requires careful monitoring for additive CNS depression and respiratory effects. 1

Key Safety Considerations

Additive Sedation Risk

• Both hydroxyzine and lorazepam are CNS depressants that can cause sedation, drowsiness, and respiratory depression when combined 1
• The first-generation antihistamine hydroxyzine demonstrates 80% sedation rates, making it one of the most sedating antihistamines available 1
• When combining these agents, use lower doses of both medications to minimize the risk of excessive sedation 1

Clinical Context Matters

For Agitation Management:

• If the patient received lorazepam for acute agitation and remains agitated, hydroxyzine can serve as an adjunctive agent 2, 3
• However, evidence suggests that in acute agitation settings, lorazepam alone may require repeat dosing (40 repeat doses in one study) compared to other agents 4
• The combination is not standard practice for acute agitation—consider whether additional lorazepam or an antipsychotic would be more appropriate 1

For Benzodiazepine Withdrawal Support:

• Hydroxyzine has demonstrated efficacy as a substitutive agent during benzodiazepine withdrawal, with significantly fewer dropouts (23.3%) compared to placebo (65.6%) 3
• In lorazepam withdrawal protocols, hydroxyzine 25-50 mg significantly improved anxiety levels and reduced withdrawal symptoms 2
• This represents a legitimate indication for combining these agents during a transition period 2, 3

For Anxiety Treatment:

• Hydroxyzine can be used alongside benzodiazepines for generalized anxiety, though this is typically done as part of a planned therapeutic regimen rather than acute dosing 5
• Studies show hydroxyzine 100 mg daily improved cognitive function better than lorazepam 4 mg daily in anxiety patients 5

Monitoring Requirements

Essential Parameters to Monitor:

• Respiratory rate and oxygen saturation - critical given additive respiratory depression risk 1
• Level of consciousness and sedation - use a validated sedation scale 1
• Blood pressure - hydroxyzine can cause orthostatic hypotension 1
• Fall risk - particularly in elderly or frail patients 1

Dosing Adjustments

When combining these agents:

• Start with hydroxyzine 25 mg rather than higher doses if lorazepam is still active 1, 2
• Consider the timing: lorazepam has a half-life of 10-20 hours, so effects may persist 2
• In elderly patients, reduce hydroxyzine dose further and monitor more closely 1
• Patients with COPD or pulmonary insufficiency require even greater caution 1

Common Pitfalls to Avoid

• Do not assume the patient needs more sedation - assess whether the underlying issue (agitation, anxiety, withdrawal) is being appropriately addressed 1
• Avoid this combination in patients with severe pulmonary insufficiency unless managing an imminently dying patient 1
• Do not use in patients with myasthenia gravis (unless end-of-life care) 1
• Watch for paradoxical agitation - both agents can cause this, particularly in elderly patients 1

Decision Algorithm

1. Identify the indication: Why was lorazepam given? Why is hydroxyzine being considered?
2. Assess current sedation level: Is the patient already adequately sedated?
3. Check contraindications: Severe pulmonary disease, myasthenia gravis, severe hepatic impairment 1
4. If proceeding, use reduced hydroxyzine dose (25 mg maximum initially) 2
5. Monitor continuously for 30-60 minutes after hydroxyzine administration 1
6. Reassess need for additional agents rather than automatically redosing 4