What is the recommended dose of Atarax (hydroxyzine) for treating anxiety in adolescents?

Atarax (Hydroxyzine) Dosing for Adolescent Anxiety

For adolescents over 6 years of age with anxiety, the FDA-approved dose of Atarax (hydroxyzine) is 50-100 mg daily in divided doses (typically given 3-4 times per day). 1

Important Context: Atarax Is Not First-Line Treatment

While hydroxyzine has FDA approval for anxiety in this age group, SSRIs (specifically sertraline or escitalopram) combined with cognitive-behavioral therapy represent the evidence-based first-line treatment for adolescent anxiety disorders, not antihistamines like Atarax. 2, 3

• The American Academy of Child and Adolescent Psychiatry recommends SSRIs as first-line pharmacotherapy for anxiety in adolescents aged 6-18 years, with sertraline typically started at 25 mg daily for week 1, then increased to 50 mg daily, with a target therapeutic dose of 50-200 mg/day. 2

• Combination treatment with CBT plus an SSRI is superior to either treatment alone, with a recommended course of 12-20 structured CBT sessions. 2

When Hydroxyzine May Be Appropriate

Hydroxyzine may be considered in specific clinical scenarios:

• As a short-term adjunct for acute anxiety symptoms while waiting for SSRIs to reach therapeutic effect (which takes 6-12 weeks). 2

• For patients who cannot tolerate or have contraindications to SSRIs, though other alternatives (SNRIs like venlafaxine) should typically be considered before antihistamines. 2

• For situational anxiety rather than chronic anxiety disorders, where the sedating effects may provide temporary relief. 1

Specific Dosing Guidelines from FDA Label

For adolescents over 6 years:

• Standard dose: 50-100 mg daily in divided doses (e.g., 12.5-25 mg three to four times daily). 1
• Dosing should be adjusted according to the patient's response to therapy. 1
• The medication can be given orally in divided doses throughout the day. 1

Critical Pitfalls to Avoid

• Do not use hydroxyzine as monotherapy for chronic anxiety disorders when evidence-based treatments (SSRIs + CBT) are available and appropriate. 2, 3, 4, 5

• Antihistamines like hydroxyzine should be approached cautiously due to potential side effects including sedation and, paradoxically, disinhibition in some children. 3

• Benzodiazepines and antihistamines lack the robust evidence base that SSRIs have for pediatric anxiety disorders, with SSRIs showing relative effectiveness along with minimal side effects and good tolerability. 4, 5

• If using hydroxyzine, monitor for excessive sedation, which may impair academic and social functioning—key quality of life outcomes in adolescents. 1

Evidence-Based Alternative Approach

If treating adolescent anxiety optimally for morbidity and quality of life outcomes:

1. Start with CBT as first-line treatment for anxiety in children and adolescents. 3

2. Add sertraline 25 mg daily if anxiety is moderate to severe, increasing to 50 mg after week 1, with monitoring for suicidal thinking especially in the first months. 2, 3

3. Reserve hydroxyzine for acute/situational use or as a bridge therapy, not as primary treatment for chronic anxiety disorders. 1