Hydroxyzine Starting Dose for Anxiety in Adults
The FDA-approved starting dose of hydroxyzine (Atarax) for anxiety in adults is 50-100 mg four times daily (q.i.d.), though clinical practice often begins at 50 mg daily in divided doses and titrates based on response. 1
Standard Adult Dosing
- The FDA label specifies 50-100 mg four times daily for symptomatic relief of anxiety and tension associated with psychoneurosis. 1
- Clinical trials have consistently used a fixed dose of 50 mg daily (typically divided as 25 mg twice daily or in other divided doses) with demonstrated efficacy superior to placebo from the first week of treatment. 2
- A study of 55 patients with generalized anxiety and somatoform disorders used 50 mg daily for 28 days with good tolerability and significant anxiety reduction. 3
Practical Dosing Strategy
- Start with 50 mg daily in divided doses (e.g., 25 mg twice daily) rather than the full FDA-labeled dose of 50-100 mg q.i.d., as this lower starting approach has proven effective in clinical trials and reduces initial sedation. 3, 2
- Assess response after 1 week of scheduled dosing, as PRN (as-needed) use is less optimal for titration purposes. 4
- The dose should be adjusted according to the patient's response to therapy, as emphasized in the FDA labeling. 1
- Efficacy is maintained throughout 4 weeks of treatment with early improvement in cognitive components of anxiety. 2
Special Population Considerations
Elderly Patients
- Reduce the starting dose to 25 mg three to four times daily (approximately 25-50% of standard adult dose) in elderly patients, titrating cautiously and slowly based on individual response. 4
- Elderly patients have increased risk of falls, cognitive impairment, and paradoxical agitation with sedating medications. 5
Important Safety Considerations
- The most common side effect is sedation/drowsiness, occurring in approximately 36% of patients, which is typically transitory. 6
- Other side effects include weakness (18%), headache (6%), and mild dry mouth (2%). 6
- Hydroxyzine lacks organ toxicity and has no dependency potential, distinguishing it from benzodiazepines. 2
- Address reversible causes of anxiety first before initiating pharmacological treatment, including exploring patient concerns and treating underlying medical conditions. 4, 7
Comparative Context
- While hydroxyzine 50 mg daily shows efficacy comparable to benzodiazepines (lorazepam, chlordiazepoxide) and buspirone, it demonstrates greater and more rapid cognitive improvement compared to lorazepam. 8, 2, 9
- However, current guidelines favor SSRIs/SNRIs as first-line for chronic anxiety disorders in most populations, with better evidence for long-term use. 4
- Benzodiazepines like lorazepam 0.25-0.5 mg are recommended by NICE as first-line for acute anxiety, particularly in elderly patients. 4