Can hydroxyzine be used safely while tapering off lorazepam (Ativan) for anxiety?

Can Hydroxyzine Be Used During Ativan (Lorazepam) Taper?

Yes, hydroxyzine can be used safely during lorazepam tapering and may actually help reduce withdrawal symptoms and anxiety, but you must reduce the lorazepam dose by approximately 25-50% when starting hydroxyzine due to additive CNS depression. 1

Critical Safety Framework

The FDA explicitly warns that hydroxyzine potentiates central nervous system depressants including benzodiazepines, and therefore when used concomitantly, the benzodiazepine dosage must be reduced. 1 This is not optional—combining full doses of both medications increases risk of oversedation, respiratory depression, confusion, and falls, particularly in elderly patients.

Dose Adjustment Protocol When Adding Hydroxyzine

• When initiating hydroxyzine during a lorazepam taper, reduce the current lorazepam dose by 25-50% immediately to account for the potentiating effect 1
• Start hydroxyzine at 25 mg three times daily (25-25-50 mg dosing pattern) rather than the full 50 mg dose to minimize initial sedation 2, 3
• Monitor closely for excessive drowsiness, confusion, dizziness, and respiratory depression at every encounter 1
• Elderly patients should start at the low end of dosing (25 mg total daily) due to increased sensitivity and risk of confusion and oversedation 1

Evidence Supporting Hydroxyzine During Benzodiazepine Withdrawal

A controlled trial specifically examined hydroxyzine as support during lorazepam withdrawal in 154 patients on chronic lorazepam (mean duration 64 months), demonstrating that hydroxyzine 50 mg significantly improved anxiety levels, reduced withdrawal symptoms, and decreased side effects compared to placebo. 2

Key Findings from Withdrawal Studies

• Hydroxyzine 50 mg provided superior reduction in withdrawal symptoms (Tyrer scale) compared to both hydroxyzine 25 mg and placebo during the 4-week withdrawal period 2
• Both hydroxyzine doses (25 mg and 50 mg) significantly improved anxiety scores (HARS and Zung scales) during withdrawal, while placebo did not 2
• After one month of withdrawal support followed by two months medication-free, 75% of patients remained off benzodiazepines with significantly decreased anxiety levels 2
• Hydroxyzine demonstrated faster and greater cognitive improvement compared to lorazepam in anxious patients, suggesting it may help reverse benzodiazepine-induced cognitive impairment during tapering 4, 3

Recommended Integration Strategy

When to Add Hydroxyzine

• Add hydroxyzine at the beginning of the taper or when withdrawal symptoms emerge during dose reductions 2
• Hydroxyzine is particularly useful for patients with marked anxiety or those experiencing withdrawal symptomatology 2

Dosing Algorithm

For moderately anxious patients:

• Hydroxyzine 25 mg three times daily (total 75 mg/day) 2
• Simultaneously reduce lorazepam by 25% of current dose 1

For highly anxious patients or those with withdrawal symptoms:

• Hydroxyzine 50 mg at bedtime plus 25 mg twice daily (total 100 mg/day) 2, 3
• Simultaneously reduce lorazepam by 50% of current dose 1

For elderly patients (≥65 years):

• Start hydroxyzine 25 mg at bedtime only 1
• Reduce lorazepam by 25% of current dose 1
• Observe closely for confusion, falls, and excessive sedation 1

Lorazepam Taper Schedule With Hydroxyzine Support

• Continue gradual lorazepam reduction by 10-25% of the current dose every 1-2 weeks (for use <1 year) or 10% per month (for use >1 year) 5
• Maintain hydroxyzine throughout the entire taper period (typically 4 weeks minimum) 2
• After completing lorazepam discontinuation, continue hydroxyzine for an additional 1-2 weeks before tapering it off 2

Expected Timeline and Outcomes

• Hydroxyzine's anxiolytic effect begins within the first week of treatment 6
• Initial daytime sleepiness typically appears during the first week but progressively diminishes with continued use 6
• The combination allows successful benzodiazepine discontinuation in approximately 75% of patients when followed by a 2-month medication-free period 2
• Progressive withdrawal is preferable to abrupt discontinuation, with fewer dropouts and better patient acceptance 2

Monitoring Requirements

Monitor at every visit for:

• Excessive sedation, drowsiness, or daytime sleepiness (most common side effect, occurring in ~28% vs 14% with placebo) 6
• Confusion or altered mental status, particularly in elderly patients 1
• Falls, dizziness, or gait instability 1
• Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, muscle aches, nausea 5
• QT prolongation risk factors if patient has cardiac disease, electrolyte abnormalities, or takes other QT-prolonging medications 1

Follow-up schedule:

• At least monthly during the taper, with more frequent contact during difficult phases 5
• Weekly contact during the first 2-4 weeks when hydroxyzine is initiated to assess sedation and dose tolerability 2

Critical Contraindications and Cautions

Avoid or use extreme caution with hydroxyzine if:

• Patient has congenital long QT syndrome, recent myocardial infarction, uncompensated heart failure, or bradyarrhythmias 1
• Patient takes other QT-prolonging medications (Class IA/III antiarrhythmics, certain antipsychotics, SSRIs, macrolide antibiotics, methadone) 1
• Patient has severe hepatic or renal impairment (start at lowest dose) 1
• Patient is elderly with cognitive impairment or fall history (maximum 25 mg/day) 1
• Patient operates machinery or drives (warn about drowsiness) 1

Adjunctive Strategies to Maximize Success

• Integrate cognitive-behavioral therapy (CBT) during the taper, which significantly increases success rates 5
• Provide patient education about benzodiazepine risks and benefits of tapering to improve engagement 5
• Consider adding gabapentin 100-300 mg at bedtime if additional withdrawal symptom management is needed, though avoid polypharmacy when possible 5
• Implement sleep hygiene education rather than substituting another sedative-hypnotic 5

Common Pitfalls to Avoid

• Never combine full doses of hydroxyzine and lorazepam without reducing the benzodiazepine—this violates FDA safety warnings 1
• Do not use hydroxyzine as a long-term benzodiazepine substitute; it is a bridge medication during the taper 2
• Do not abruptly discontinue lorazepam even with hydroxyzine support—gradual tapering remains essential to prevent seizures and death 5
• Do not abandon the patient if tapering is unsuccessful; maintenance at a lower dose is an acceptable outcome 5
• Avoid prescribing additional CNS depressants (opioids, Z-drugs, other benzodiazepines) during the taper period 5

When to Refer to Specialist

• History of withdrawal seizures 5
• Unstable psychiatric comorbidities 5
• Co-occurring substance use disorders 5
• Previous unsuccessful office-based tapering attempts 5
• Pregnant patients (benzodiazepine withdrawal can cause spontaneous abortion and premature labor) 5