Atarax (Hydroxyzine) Should Be Avoided in Elderly Patients with CKD and Acute Anxiety
Hydroxyzine is specifically identified as a potentially inappropriate medication (PIM) requiring deprescription in elderly patients with advanced chronic kidney disease, and should not be used for acute anxiety management in this population. 1
Why Hydroxyzine is Inappropriate in This Context
Specific Contraindications in Elderly CKD Patients
Hydroxyzine is explicitly listed among anticholinergic drugs that warrant deprescription in elderly patients with advanced CKD, alongside long-term benzodiazepines and rilmenidine. 1
The medication carries significant risks in elderly populations including sedation, cognitive impairment, unsafe mobility with injurious falls, and motor skill impairment. 2
Elderly patients are more susceptible to confusion and over-sedation from sedating drugs like hydroxyzine, and the FDA label specifically recommends starting elderly patients on low doses with close observation due to these risks. 3
Renal Considerations
The extent of renal excretion of hydroxyzine has not been determined, making dose adjustment in CKD uncertain and potentially dangerous. 3
The FDA label explicitly states that elderly patients are more likely to have decreased renal function, requiring cautious dose selection, but provides no specific guidance for CKD patients. 3
In a study of elderly patients with advanced CKD (eGFR <20 mL/min/1.73 m²), hydroxyzine was identified as one of the PIMs for which deprescription is especially important. 1
Additional Safety Concerns
Hydroxyzine carries risks of QT prolongation and Torsade de Pointes, particularly problematic in patients with CKD who often have electrolyte imbalances and other cardiac risk factors. 3
The drug should be used with extreme caution in patients with pre-existing heart disease, electrolyte imbalances, or concomitant arrhythmogenic drug use—all common in elderly CKD patients. 3
Acute Generalized Exanthematous Pustulosis (AGEP) is a rare but serious skin reaction associated with hydroxyzine that requires immediate discontinuation. 3
Recommended Alternatives for Acute Anxiety in Elderly CKD Patients
First-Line Pharmacologic Options
SSRIs and SNRIs are considered first-line treatment for anxiety in elderly patients, with efficacy and good tolerability profiles. 4
Select SSRIs with favorable pharmacokinetic profiles and less cytochrome P450 inhibition to minimize drug interactions in this polypharmacy-prone population. 4
Mirtazapine and vortioxetine are also considered safe treatment options for anxiety in elderly patients. 4
Short-Term Benzodiazepine Use (With Caution)
For acute anxiety management specifically, benzodiazepines metabolized by the liver (diazepam 0.1-0.8 mg/kg orally or midazolam 0.5-1 mg/kg, max 15 mg) can be used without dose adjustment in CKD. 5
However, benzodiazepines should only be used short-term due to risks of cognitive impairment, falls, fractures, and addiction in elderly patients. 2
High potency, long-acting, or prolonged use of benzodiazepines are considered high risk by Beers criteria and should be avoided. 2
Non-Pharmacologic Approaches
Cognitive-behavioral therapy and problem-solving interventions should be considered as safer alternatives to pharmacologic management. 2
Psychological treatments and interpersonal support can effectively manage anxiety without medication-related risks. 2
Critical Clinical Pitfalls to Avoid
Do not assume normal serum creatinine indicates normal renal function in elderly patients—GFR decreases approximately 8 mL/min each decade after age 40, and CKD is often unrecognized. 2
Avoid polypharmacy-related medication errors by ensuring medication reconciliation, especially during transitions of care. 2
Never use antipsychotics for anxiety management in elderly patients with dementia—they carry an FDA black box warning for increased mortality risk. 2, 4
Tricyclic antidepressants and MAOIs should not be used despite potential efficacy, due to suboptimal side effect and safety profiles in elderly patients. 4