From the Guidelines
Hydroxyzine should not be used as a first-line treatment for insomnia due to its potential for adverse effects and the availability of more effective and safer alternatives, such as cognitive behavioral therapy for insomnia (CBT-I) 1. When considering the use of hydroxyzine for insomnia, it's essential to weigh the potential benefits against the risks. Hydroxyzine is an antihistamine that can cause drowsiness as a side effect, which is why some healthcare providers prescribe it off-label for sleep difficulties. However, the evidence suggests that its use is not recommended for chronic insomnia due to the potential for tolerance, dependence, and adverse effects such as daytime drowsiness, dry mouth, and dizziness 1. The American College of Physicians recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful 1. Some key points to consider when evaluating the use of hydroxyzine for insomnia include:
- Typical dosing for sleep ranges from 25-50mg taken 30 minutes before bedtime
- Hydroxyzine works by blocking histamine H1 receptors in the brain, which produces sedative effects
- It should only be used temporarily for insomnia as tolerance can develop with regular use, making it less effective over time
- Side effects may include daytime drowsiness, dry mouth, and dizziness
- Patients with certain conditions like narrow-angle glaucoma, prostate enlargement, or who are taking certain medications should avoid hydroxyzine
- Always consult with a healthcare provider before using any medication for sleep problems 1.
From the FDA Drug Label
For symptomatic relief of anxiety and tension associated with psychoneurosis and as an adjunct in organic disease states in which anxiety is manifested. As a sedative when used as a premedication and following general anesthesia, hydroxyzine may potentiate meperidine and barbiturates, so their use in pre-anesthetic adjunctive therapy should be modified on an individual basis.
The primary use of hydroxyzine is for anxiety and tension associated with psychoneurosis, and as a sedative in certain medical situations.
- It is not explicitly indicated for insomnia in the provided drug label.
- However, its sedative properties might be useful in managing insomnia, but this is not a direct or approved use according to the label 2.
From the Research
Hydroxyzine for Insomnia
- Hydroxyzine is an antihistamine that has been used off-label for the treatment of insomnia, but its efficacy and safety for this indication are not well established 3.
- A systematic review of five studies, including one open-label and four randomized controlled trials, found mixed efficacy of hydroxyzine for sleep measures, including sleep onset, sleep maintenance, and sleep quality 3.
- The most common adverse drug effect reported was dry mouth, although safety outcomes were not well reported in most of the studies 3.
- Another study found that hydroxyzine impaired performance on cognitive tasks, with greater impairment after morning doses compared to evening doses 4.
- In contrast, eszopiclone, a non-benzodiazepine sedative-hypnotic agent, has been shown to be effective and well-tolerated for the treatment of insomnia, with a favorable safety profile 5, 6.
- The use of hydroxyzine for insomnia is not supported by strong evidence, and its role in the treatment of insomnia is not well established 3.
- Further studies are needed to fully evaluate the efficacy and safety of hydroxyzine for insomnia, particularly in comparison to other established treatments like eszopiclone 3.