Can Hydroxyzine (Atarax) and Trazodone Be Combined?
Yes, hydroxyzine and trazodone can be safely combined for insomnia and anxiety, with no absolute contraindications existing between these medications according to current American Academy of Sleep Medicine guidelines. 1
Why This Combination Works
Both medications target sleep-wake mechanisms through different pathways—trazodone works primarily through alpha2-adrenergic and 5-HT2/1C receptor antagonism, while hydroxyzine acts as an antihistamine with sedative properties. 1
The combination provides complementary therapeutic effects and is preferable to benzodiazepines, which carry significant risks of dependency, diversion, falls, and cognitive impairment according to 2019 VA/DoD guidelines. 1
Hydroxyzine monotherapy develops tolerance to sedative effects after only 3-4 days of continuous use, making combination therapy with trazodone more rational for sustained treatment. 1
Critical Precautions for Safe Use
Additive Sedation Management
Start with lower doses of each medication when combining them—the sedative effects are additive and require careful dosage adjustments to avoid excessive sedation. 1
Administer both medications at bedtime to maximize sleep benefits and minimize daytime impairment. 1
Patients must be warned about increased drowsiness and cautioned against activities requiring alertness, especially during the initial treatment period. 1
Specific Dosing Recommendations
Trazodone: Start at 25-50mg at bedtime, can increase to 100mg as needed. 2
Hydroxyzine: Use standard dosing but consider starting at the lower end when combined.
Avoid combining with other CNS depressants including alcohol, which could dangerously increase sedation. 1, 2
Special Population Considerations
Elderly patients require lower doses of both medications due to increased sensitivity to sedative effects. 1, 2
Patients with hepatic impairment need dosage adjustments for both agents. 1
Those with respiratory conditions should use this combination with caution due to CNS depressant effects. 1
Essential Monitoring
Monitor for excessive daytime sedation, particularly during the first few weeks of combined use. 1, 2
Assess efficacy for sleep improvement and any adverse effects at follow-up appointments. 1
Regular follow-up every few weeks during initial treatment is recommended to optimize dosing. 2
Important Safety Note
- While an older 1975 study suggested hydroxyzine might produce abnormal ventricular repolarization when combined with certain medications 3, current American Academy of Sleep Medicine guidelines do not list this as a contraindication for the trazodone-hydroxyzine combination, and no specific cardiac monitoring requirements are mentioned in contemporary guidelines. 1