What is the normal dose of Atarax (hydroxyzine) for anxiety as needed?

Hydroxyzine (Atarax) Dosing for As-Needed Anxiety

For as-needed anxiety management, the FDA-approved dose of hydroxyzine is 50-100 mg up to four times daily in adults, though current clinical guidelines strongly favor benzodiazepines like lorazepam 0.5-1 mg as first-line therapy for acute anxiety instead. 1, 2

FDA-Approved Dosing

• Adults: 50-100 mg four times daily for symptomatic relief of anxiety and tension associated with psychoneurosis 1
• Children under 6 years: 50 mg daily in divided doses 1
• Children over 6 years: 50-100 mg daily in divided doses 1
• Elderly/debilitated patients: Start at 25-50% of standard adult dose (approximately 25 mg three to four times daily) and titrate cautiously 3

Critical Limitation for PRN Use

Hydroxyzine requires 1 week of scheduled dosing for optimal assessment of response, making PRN (as-needed) use suboptimal for titration and potentially less effective than scheduled dosing. 2, 3 This represents a significant practical limitation when patients specifically request "as-needed" anxiety medication.

Guideline-Recommended Alternative

NICE guidelines recommend benzodiazepines as first-line pharmacological treatment for acute anxiety rather than hydroxyzine: 2, 4

• Lorazepam 0.5-1 mg orally up to four times daily as needed for adults 2, 4
• Lorazepam 0.25-0.5 mg (maximum 2 mg in 24 hours) for elderly or debilitated patients 2, 4

The use of hydroxyzine as first-line should be avoided when benzodiazepines are appropriate and not contraindicated, due to stronger guideline support for benzodiazepines in acute anxiety management. 2

Efficacy Evidence

Research demonstrates hydroxyzine's effectiveness, though with important caveats:

• Hydroxyzine 50 mg daily showed statistically significant anxiolytic effect versus placebo in controlled trials, with benefits appearing within the first week 5
• A Cochrane review concluded hydroxyzine is more effective than placebo but noted high risk of bias in included studies and could not recommend it as reliable first-line treatment 6
• Clinical studies using 50 mg daily showed excellent/good results in 66% of patients with generalized anxiety 7

Common Side Effects

The most frequent side effect is transient sleepiness/drowsiness (28-36% of patients), which typically appears during the first week and progressively diminishes with continued treatment: 5, 7

• Weight gain (12%) 5
• Dry mouth (14%) 5
• Loss of concentration (9%) 5
• Weakness (18%) 7
• Rare allergic reactions including urticaria 7

Practical Clinical Algorithm

When a patient requests as-needed anxiety medication:

1. First-line: Consider lorazepam 0.5-1 mg PRN (if no contraindications to benzodiazepines) 2, 4
2. If benzodiazepines contraindicated: Hydroxyzine 50-100 mg can be used, but counsel patient that scheduled dosing (not PRN) for at least 1 week provides better assessment of efficacy 1, 2
3. For elderly patients: Reduce to lorazepam 0.25-0.5 mg or hydroxyzine 25 mg 2, 3
4. Always address reversible causes first: Explore patient concerns, ensure effective communication, treat underlying medical conditions before initiating pharmacological treatment 4, 3