What can be used for anxiety management if Vistaril (hydroxyzine) is discontinued?

Alternative Medications for Anxiety After Vistaril (Hydroxyzine) Discontinuation

SSRIs, specifically escitalopram (10-20 mg/day) or sertraline (50-200 mg/day), should be your first-line replacement for hydroxyzine in treating chronic anxiety disorders. 1

First-Line Pharmacologic Options

Preferred SSRIs

• Escitalopram is the optimal initial choice due to its superior efficacy, favorable drug interaction profile (minimal CYP450 effects), and lower discontinuation rates 2, 1

  • Start at 5-10 mg daily and titrate by 5-10 mg increments every 1-2 weeks 1
  • Target dose: 10-20 mg/day 2, 1
  • Begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation 2

• Sertraline is an equally effective alternative with extensive safety data 2, 1

  • Start at 25-50 mg daily and titrate by 25-50 mg increments every 1-2 weeks 1
  • Target dose: 50-200 mg/day 1
  • Lower risk of QTc prolongation compared to escitalopram 2

Expected Timeline

• Statistically significant improvement begins by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 1
• Do not abandon treatment prematurely—full response may require 12+ weeks 1
• Allow 1-2 weeks between dose increases to assess tolerability 1

Alternative First-Line: SNRIs

If SSRIs are contraindicated or not tolerated:

• Venlafaxine extended-release (75-225 mg/day) is effective across all anxiety disorders 1

  • Requires blood pressure monitoring due to risk of sustained hypertension 1
  • Demonstrates greater efficacy for treatment-resistant cases compared to continuing SSRI therapy 2

• Duloxetine (60-120 mg/day) is particularly beneficial for patients with comorbid pain conditions 1

  • Start at 30 mg daily for one week to reduce nausea, then increase to 60 mg 1

Non-SSRI/SNRI Option: Buspirone

Buspirone is a viable anxioselective alternative without sedative properties or dependence risk 3, 4, 5

• Acts on 5-HT1A serotonin receptors rather than GABA receptors, providing anxiolytic effects without sedation, muscle relaxation, or abuse potential 4
• Demonstrated efficacy comparable to benzodiazepines and hydroxyzine in controlled trials 6, 7
• Safe for long-term use up to one year with no withdrawal syndrome upon discontinuation 5
• Most common side effects: dizziness (12%), drowsiness (10%), nervousness (5%) 3
• Critical caveat: Buspirone requires 2-4 weeks to achieve full anxiolytic effect, unlike hydroxyzine's immediate action 6

Combining Medication with Psychotherapy

Adding cognitive behavioral therapy (CBT) to medication provides superior outcomes compared to either treatment alone 2, 1

• Individual CBT demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 1
• The combination of SSRI with CBT has demonstrated greater efficacy than monotherapy in controlled studies 2

Critical Monitoring Requirements

• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments (pooled risk difference 0.7% vs placebo) 1
• Assess response using standardized anxiety rating scales such as HAM-A 2, 1
• Common SSRI/SNRI side effects: nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness 1
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1

Medications to Avoid

• Benzodiazepines carry significant dependence risk and should not be used as routine replacements for hydroxyzine 8
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1
• Beta blockers (atenolol, propranolol) are deprecated based on negative evidence 1

Treatment Algorithm for Inadequate Response

If first SSRI fails after 8-12 weeks:

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) rather than increasing to supramaximal doses 1
2. Consider switching to an SNRI such as venlafaxine 2, 1
3. Add CBT if not already implemented 1