hydroxyzine

Adjunctive therapy

Brands: VISTARIL, ATARAX

Last reviewed 2025-12-28

Reviewed by PsychMed Editorial Team.

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Quick answers

What is hydroxyzine?
Hydroxyzine (brands Vistaril/Atarax) is a first-generation antihistamine used for anxiety symptoms, pruritus, and procedural sedation. In psychiatry it is commonly used as a short-term, “as needed” calming agent when clinicians want to avoid benzodiazepines.
What is VISTARIL?
VISTARIL is a brand name for hydroxyzine (other brands: ATARAX).
What is VISTARIL (hydroxyzine) used for?
Label indications include: Anxiety symptoms (label); pruritus; pre/postoperative sedation (label varies by product).
What drug class is VISTARIL (hydroxyzine)?
First-generation antihistamine (H1 antagonist) with sedating and anxiolytic effects; anticholinergic/antiemetic properties.
What strengths does VISTARIL (hydroxyzine) come in?
Oral tablets (hydroxyzine HCl) and oral capsules (hydroxyzine pamoate) are commonly used; strengths vary by manufacturer.
What is hydroxyzine hydrochloride (HCl)?
Two oral salt forms are used clinically (hydroxyzine hydrochloride and hydroxyzine pamoate). Both are sedating and can impair driving and increase fall risk.

Snapshot

Class: Adjunctive therapy
Common US brands: VISTARIL, ATARAX
Therapeutic drug monitoring not routinely recommended.
Last reviewed: 2025-12-28

Label indications

Anxiety symptoms (label); pruritus; pre/postoperative sedation (label varies by product).

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Clinical Highlights

Hydroxyzine (brands Vistaril/Atarax) is a first-generation antihistamine used for anxiety symptoms, pruritus, and procedural sedation. In psychiatry it is commonly used as a short-term, “as needed” calming agent when clinicians want to avoid benzodiazepines. Two oral salt forms are used clinically (hydroxyzine hydrochloride and hydroxyzine pamoate). Both are sedating and can impair driving and increase fall risk.

Because it is anticholinergic and sedating, hydroxyzine can worsen confusion, constipation, and urinary retention—especially in older adults; it is often used as a short-term PRN bridge rather than a chronic daily medication.
QT risk is a key limiter: it is generally avoided in patients with known prolonged QT, and risk is lower when electrolyte abnormalities are addressed and combinations with other QT-risk agents are minimized when possible.
The compare view and the hydroxyzine evidence feed, along with the hydroxyzine print page can support side-by-side review and patient-friendly counseling on safe, time-limited use.
Labels cover anxiety symptoms and pruritus; for persistent anxiety, psychotherapy and SSRI/SNRI strategies are typically emphasized, with hydroxyzine used as a time-limited adjunct.
Generic formulations are widely available; refill momentum can turn PRN use into chronic daily use without reassessment.

Dosing & Formulations

Common oral formulations include tablets (hydroxyzine HCl) and capsules (hydroxyzine pamoate); strengths vary by manufacturer. Anxiety/acute distress (off label patterns vary): 25–50 mg every 6–8 hours as needed; start lower (10–25 mg) in older adults or when fall risk is high.

Insomnia symptoms (off label): 25–50 mg at bedtime as needed; nightly indefinite use is generally avoided.
Combining with other sedatives can increase impairment; follow-up within days to weeks helps prevent automatic refills.
If daytime use is considered, counseling about driving impairment and lowest-effective dosing is common; many patients do better with bedtime use only.

Monitoring & Risks

Sedation and impaired coordination: Counseling often covers driving, machinery, and falls; effects can persist into the next day. Anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision): Higher risk in older adults and those with BPH or glaucoma.

QT prolongation/torsades risk: generally avoided with known prolonged QT; caution is warranted when combined with QT-risk antipsychotics or methadone.
Rare serious skin reactions (AGEP) and hypersensitivity; the label warns about cross-sensitivity, and cetirizine/levocetirizine are generally avoided in patients with hydroxyzine hypersensitivity.

Drug Interactions

Additive CNS depression with alcohol, opioids, benzodiazepines, and sedating antipsychotics—when combinations occur, the lowest effective doses and explicit counseling are typical. Additive QT risk with other QT-prolonging drugs; consider ECG monitoring when risk factors stack.

Additive anticholinergic burden with low-potency antipsychotics and bladder antimuscarinics increases delirium and urinary retention risk.

Practice Notes

Hydroxyzine is often used as a short-term PRN bridge while primary anxiety therapies (SSRIs/SNRIs, psychotherapy, sleep interventions) take effect. Chronic daily use in older adults is generally avoided when possible; alternatives often include buspirone, SSRI/SNRI strategies, or non-sedating options.

If QT risk factors exist (cardiac disease, electrolyte issues, multiple QT meds), baseline ECGs are often considered and alternatives may be preferred when feasible.
Short prescriptions with planned follow-up and a documented stop plan can reduce refill momentum; when anxiety remains frequent, the focus often shifts to primary therapy rather than escalating PRN sedatives.

References

Hydroxyzine hydrochloride prescribing information — DailyMed (2025)
Hydroxyzine pamoate prescribing information — DailyMed (2025)
Evidence Based Pharmacological Treatment OF Anxiety Disorders — Depression and Anxiety (2014)
NEW Restrictions TO Minimise THE Risks OF Effects ON Heart Rhythm With Hydroxyzine Containing Medicines — European Medicines Agency (2015)
Guidelines FOR THE Pharmacological Treatment OF Anxiety Disorders, Obsessive Compulsive Disorder AND Posttraumatic Stress Disorder IN Primary Care — International Journal of Psychiatry in Clinical Practice (2012)