What is the efficacy of hydroxyzine (Atarax) for insomnia?

From the Guidelines

Hydroxyzine should not be used as a treatment for chronic insomnia disorder due to its antimuscarinic adverse effect profile and the potential for tolerance to its sedative effects. The use of hydroxyzine for sleep is not recommended, especially in older adults, as it can cause significant adverse effects, including dry mouth, blurred vision, constipation, and daytime sleepiness 1. The 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines advise against the use of antihistamines, such as hydroxyzine, for the treatment of chronic insomnia disorder, citing the lack of evidence supporting their efficacy and the potential for harm 1. Some key points to consider when evaluating the use of hydroxyzine for sleep include:

• The potential for tolerance to its sedative effects after 3 to 4 days of continuous use
• The antimuscarinic adverse effect profile, which can be particularly problematic in older adults
• The lack of evidence supporting the use of hydroxyzine as a treatment for chronic insomnia disorder
• The availability of alternative treatments, such as nonbenzodiazepine BZRAs, which may be more effective and safer for long-term use 1. In general, it is recommended to prioritize non-pharmacological interventions, such as addressing underlying causes of insomnia and practicing good sleep hygiene, over the use of medications like hydroxyzine for the treatment of chronic insomnia disorder.

From the Research

Hydroxyzine for Sleep

• Hydroxyzine is a medication that has been studied for its efficacy and safety in treating insomnia in adults 2.
• A systematic review of five articles, including one open-label and four randomized controlled trials, found mixed efficacy in sleep measures such as sleep onset, sleep maintenance, and sleep quality 2.
• The most common adverse drug effect reported was dry mouth, although safety outcomes were not reported in four of the five studies 2.
• The studies suggest that hydroxyzine could be considered as a short-term treatment option for adults with insomnia who have not responded to previous therapy or have contraindications 2.
• However, additional long-term studies with an active comparator are needed to further establish its role in insomnia treatment 2.

Comparison with Other Sleep Aids

• Eszopiclone, a nonbenzodiazepine sedative-hypnotic agent, has been shown to be effective in treating transient and chronic insomnia 3, 4, 5, 6.
• Eszopiclone has a rapid absorption and elimination half-life, and is extensively metabolized by oxidation and demethylation 6.
• Clinical trials have demonstrated the efficacy and safety of eszopiclone in improving sleep efficiency, sleep latency, and wake time after sleep onset 3, 4, 5, 6.
• The most commonly reported adverse events associated with eszopiclone were bitter taste, dizziness, and dry mouth 6.
• Unlike hydroxyzine, eszopiclone has been studied in more extensive clinical trials, including long-term studies, and has been shown to be effective and well-tolerated in treating insomnia 3, 4, 5, 6.