Can Trazodone and Atarax (Hydroxyzine) Be Given Together?
You should avoid combining trazodone and hydroxyzine (Atarax) because both agents prolong the QTc interval, and their concurrent use significantly increases the risk of life-threatening cardiac arrhythmias, particularly torsades de pointes.
Cardiac Safety Concerns
Hydroxyzine is explicitly listed as a QT-interval-prolonging medication in pediatric and adult populations, and guidelines warn against combining it with other drugs that have arrhythmic properties 1.
Tricyclic antidepressants (including structurally related agents like trazodone) should not be taken concurrently with drugs that have potential arrhythmic properties, and the combination with antihistamines that prolong QTc is specifically contraindicated 1.
The risk of QTc prolongation and dysrhythmia is amplified when multiple QT-prolonging medications are used together, creating additive cardiac toxicity that can result in sudden cardiac death 1.
Central Nervous System Depression Risks
Both trazodone and hydroxyzine are sedating agents that produce additive CNS depression, increasing the risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors 1, 2.
Combining multiple sedating medications markedly increases psychomotor impairment and fall risk, especially in elderly patients who are already at heightened risk for fractures 1, 2.
Safer Alternative Approaches
For Insomnia Management
Initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment before adding any pharmacotherapy, as it provides superior long-term efficacy without cardiac or sedation risks 3, 2.
If pharmacotherapy is required after CBT-I initiation, use low-dose doxepin 3-6 mg, which has minimal anticholinergic effects, no QTc prolongation, and no abuse potential 2.
Alternatively, consider ramelteon 8 mg or suvorexant 10 mg, both of which avoid QTc prolongation and have lower risk profiles than combining sedating antihistamines with trazodone 2.
For Anxiety Management
If hydroxyzine is being used for anxiety, consider switching to an SSRI (such as sertraline) or buspirone, which do not carry the same QTc prolongation risk when combined with other medications 1, 2.
Avoid using sedating antihistamines as monotherapy for chronic conditions, as they lack efficacy data, cause anticholinergic side effects, and develop tolerance within 3-4 days 2.
Critical Monitoring If Combination Cannot Be Avoided
If clinical circumstances absolutely require concurrent use, obtain a baseline ECG and monitor QTc interval closely, discontinuing both agents immediately if QTc exceeds 500 ms or increases by >60 ms from baseline 1.
Assess for additional risk factors including female sex, age >65 years, hypokalemia, hypomagnesemia, bradycardia, and concomitant use of other QT-prolonging drugs (macrolides, fluoroquinolones, antiarrhythmics) 1.
Monitor for signs of excessive sedation, confusion, falls, and respiratory depression, particularly during the first 24-48 hours after initiation 1, 2.
Common Pitfalls to Avoid
Do not confuse hydroxyzine with second-generation antihistamines like loratadine, which do not share the cardiac arrhythmia and QTc-prolongation risk and can be safely combined with trazodone 3.
Avoid prescribing trazodone for primary insomnia, as guidelines explicitly recommend against its use due to minimal benefit (only ~10 minutes reduction in sleep latency) and harms that outweigh benefits 2.
Do not add hydroxyzine to trazodone simply to augment sedation, as this creates dangerous polypharmacy with cumulative cardiac and CNS risks that far exceed any potential therapeutic benefit 1, 2.