In a 52‑year‑old man taking sertraline 200 mg daily, trazodone 200 mg at bedtime, and hydroxyzine 50 mg three times daily (GAD‑7 score 4), what safe non‑sedating anxiolytic can be added to replace the scheduled hydroxyzine?

Replacing Hydroxyzine with a Non-Sedating Anxiolytic

Buspirone is the safest non-sedating anxiolytic to add and replace scheduled hydroxyzine in this patient already taking sertraline 200 mg and trazodone 200 mg, particularly given the low GAD-7 score of 4 indicating minimal anxiety. 1, 2

Rationale for Buspirone

• Buspirone is specifically recommended for mild to moderate anxiety with an initial dose of 5 mg twice daily, which can be titrated to a maximum of 20 mg three times daily (60 mg/day total). 1, 2

• Buspirone has no sedative properties, making it ideal for daytime use without the drowsiness associated with hydroxyzine. 1

• Buspirone has no interaction concerns with sertraline or trazodone and does not add to sedation burden. 1

• The onset of action is 2-4 weeks, so overlap hydroxyzine tapering with buspirone initiation to prevent breakthrough anxiety. 1, 2

Practical Implementation Algorithm

Step 1: Initiate Buspirone

• Start buspirone 5 mg twice daily (morning and afternoon). 1
• Continue hydroxyzine 50 mg three times daily during the first week. 1

Step 2: Taper Hydroxyzine (Week 2-4)

• Week 2: Reduce hydroxyzine to 50 mg twice daily, increase buspirone to 7.5 mg twice daily. 1
• Week 3: Reduce hydroxyzine to 50 mg once daily at bedtime, increase buspirone to 10 mg twice daily. 1
• Week 4: Discontinue hydroxyzine, maintain buspirone 10 mg twice daily. 1

Step 3: Optimize Buspirone Dose

• After 2-4 weeks at 10 mg twice daily, assess response. 1, 2
• If needed, titrate to 15 mg twice daily, then 20 mg twice daily based on anxiety control. 1

Critical Safety Considerations

Avoid benzodiazepines in this patient despite their anxiolytic efficacy, as they carry risks of tolerance, addiction, cognitive impairment, and paradoxical agitation in approximately 10% of elderly patients. 2

The current trazodone 200 mg dose is already at the upper therapeutic range for antidepressant/anxiolytic effects and should not be increased further, as higher doses (above 300 mg) may paradoxically reduce efficacy. 3, 4

Sertraline 200 mg is at maximum recommended dose and further increases are not indicated. 5

Why Not Other Options

• SNRIs (duloxetine, venlafaxine) would be redundant given the patient is already on maximum-dose sertraline and could increase serotonergic side effects. 1

• Increasing trazodone is not advisable as the patient is already at 200 mg daily, and doses above 300-400 mg show diminishing returns with increased side effects. 3, 6, 4

• Gabapentin or pregabalin are not first-line for generalized anxiety and would add unnecessary sedation to an already sedating regimen. 1

Monitoring Parameters

• Reassess GAD-7 score at 4 weeks after hydroxyzine discontinuation to confirm buspirone efficacy. 1

• Monitor for buspirone side effects including dizziness, headache, and nausea, which are typically mild and transient. 1

• Assess daytime sedation improvement as hydroxyzine is tapered, which should enhance quality of life and function. 1, 2