Hydroxyzine HCl for Acute Anxiety in Adults
Yes, hydroxyzine HCl can be used for acute anxiety in adults, with FDA-approved dosing of 50-100 mg four times daily for symptomatic relief of anxiety and tension associated with psychoneurosis. 1
FDA-Approved Indication and Dosing
- Hydroxyzine is FDA-approved specifically for symptomatic relief of anxiety and tension associated with psychoneurosis and as an adjunct in organic disease states where anxiety is manifested. 1
- Standard adult dosing: 50-100 mg four times daily (QID). 1
- Dosage should be adjusted according to the patient's response to therapy. 1
Evidence for Efficacy
- Hydroxyzine demonstrates superiority over placebo for generalized anxiety disorder, with statistically significant reduction in anxiety scores beginning in the first week of treatment. 2, 3
- The anxiolytic effect is maintained throughout 4 weeks of treatment and persists after abrupt discontinuation without rebound anxiety or withdrawal symptoms. 3
- Hydroxyzine shows equivalent efficacy to benzodiazepines (chlordiazepoxide) and buspirone in treating anxiety, with comparable acceptability and tolerability profiles. 2
- Clinical trials demonstrate greater and more rapid cognitive improvement compared to lorazepam. 4
Major Contraindications and Warnings
Cardiac Risks
- QT prolongation and Torsade de Pointes: Cases reported during post-marketing surveillance, particularly in patients with pre-existing risk factors. 1
- Use with caution in patients with: congenital long QT syndrome, family history of long QT syndrome, recent myocardial infarction, uncompensated heart failure, bradyarrhythmias, and electrolyte imbalances. 1
- Avoid concomitant use with Class 1A antiarrhythmics (quinidine, procainamide), Class III antiarrhythmics (amiodarone, sotalol), certain antipsychotics (ziprasidone, quetiapine, clozapine), certain antidepressants (citalopram, fluoxetine), and certain antibiotics (azithromycin, erythromycin, moxifloxacin). 1
CNS Depression
- Potentiates central nervous system depressants: When used with narcotics, non-narcotic analgesics, barbiturates, or alcohol, reduce the dosage of these concomitant agents. 1
- Patients must be warned against driving or operating dangerous machinery due to drowsiness. 1
- Avoid simultaneous use of other CNS depressant drugs. 1
Dermatologic Reactions
- Acute Generalized Exanthematous Pustulosis (AGEP): Rare but serious skin reaction characterized by fever and sterile pustules. 1
- Discontinue hydroxyzine immediately at first appearance of skin rash or worsening of pre-existing skin reactions. 1
- Avoid cetirizine or levocetirizine in patients with prior hydroxyzine hypersensitivity due to cross-sensitivity risk. 1
Geriatric Considerations
- Start elderly patients on low doses due to greater frequency of decreased hepatic, renal, or cardiac function. 1
- Sedating drugs may cause confusion and over-sedation in the elderly. 1
- Anticholinergic burden is a significant concern in elderly populations, affecting memory and cognitive function. 5
Comparative Context with Guidelines
While current anxiety disorder guidelines prioritize SSRIs and SNRIs as first-line pharmacotherapy for generalized anxiety disorder and social anxiety disorder 6, hydroxyzine remains a valid FDA-approved option for acute symptomatic relief. 1 Guidelines note that benzodiazepines carry increased risk of abuse, dependence, and cognitive impairment, recommending time-limited use. 6 Hydroxyzine offers an alternative with demonstrated lack of dependency and absence of withdrawal symptoms upon discontinuation. 4, 3
Common Side Effects
- Sleepiness/drowsiness: Most common side effect (28% vs 14% placebo), appearing during the first week and progressively diminishing during continued treatment. 3
- Weight gain (12%), dry mouth (14%), loss of concentration (9%), and insomnia (9%) reported in clinical trials. 3
- Overall side effect profile shows 52% reporting adverse effects versus 35% with placebo. 3