Hydroxyzine Use in Older Adults: Guidelines and Precautions

Risks of Hydroxyzine in Older Adults

Older adults are more sensitive to the psychomotor impairment caused by first-generation antihistamines like hydroxyzine, leading to increased risk of falls, fractures, and subdural hematomas 1, 2
Anticholinergic effects of hydroxyzine are particularly problematic in older adults, including dry mouth, dry eyes, constipation, urinary retention, and increased risk of narrow-angle glaucoma 1, 2
Comorbid conditions common in older adults increase the risks associated with hydroxyzine use 2
Sedating effects persist longer than plasma levels of the medication, causing next-day impairment even when taken at bedtime 1

Second-generation antihistamines are strongly preferred for older adults due to less sedation and fewer anticholinergic effects 1, 2
Fexofenadine, loratadine, and desloratadine at recommended doses do not cause sedation and are safer options 2
If an antihistamine is needed for sleep, the risks of next-morning impairment should be carefully considered, as performance impairment can occur without subjective awareness of drowsiness 2

In moderate renal impairment, the dose of hydroxyzine should be halved 3, 4
Hydroxyzine should be avoided in severe liver disease due to its inappropriate sedating effects 4, 5
For patients with liver impairment, loratadine, desloratadine, or fexofenadine are preferred alternatives 5

Consider starting at 10-25 mg once daily at bedtime if absolutely necessary, though safer alternatives should be sought 6

While hydroxyzine has shown efficacy, the risks in older adults generally outweigh the benefits 6

First, determine if an antihistamine is truly necessary 3
If yes, select a second-generation antihistamine (fexofenadine, loratadine, or desloratadine) 1, 2
If sedation is desired for sleep, consider that even nighttime dosing of hydroxyzine can cause next-day impairment 1
For patients with renal or hepatic impairment, further adjust selection based on specific contraindications 3, 4, 5
Monitor closely for adverse effects including sedation, falls, confusion, dry mouth, constipation, and urinary retention 1, 2

The American Academy of Allergy, Asthma, and Immunology recommends that cetirizine, a second-generation antihistamine, may cause sedation even at recommended doses, distinguishing it from truly non-sedating second-generation antihistamines like fexofenadine, loratadine, and desloratadine 7

Older adults are more sensitive to psychomotor impairment from antihistamines with sedating properties, increasing risk of falls, fractures, and subdural hematomas 7
The Lancet Healthy Longevity guidelines emphasize that use of concomitant drugs is among the key risk factors requiring assessment in individuals with dementia and frailty 8, 9, 10, 11

The Lancet guidelines explicitly recommend systematic medication review and deprescribing of unnecessary or inappropriate medications using STOPP/START or Beers criteria, particularly critical for fall prevention in individuals with dementia and frailty 8, 9, 10, 11
Medication review is a key intervention strategy for fall prevention in individuals with dementia and frailty, with psychotropic medications carrying an odds ratio of 1.7 for falls 9, 8, 12

Fexofenadine, loratadine, or desloratadine are recommended as first choice when antihistamine therapy is truly indicated, as they do not cause sedation at recommended doses and are strongly preferred for older adults 7

The Lancet Healthy Longevity guidelines recommend assessing necessity of antihistamine use and deprescribing immediately if unnecessary, as part of comprehensive medication review 8, 9
If antihistamine use is necessary, switching to fexofenadine, loratadine, or desloratadine is recommended, with implementation of multimodal fall prevention strategies including physical exercise, environmental modifications, gait assessment, and ongoing medication monitoring 7, 8, 9, 10

First-generation antihistamines like hydroxyzine are central nervous system depressants that can precipitate hepatic encephalopathy, a life-threatening complication in cirrhosis, in patients with cirrhosis, particularly those with severe liver disease 13
Patients with mild-to-moderate cirrhosis (Child-Pugh A-B) without encephalopathy should be monitored closely for signs of encephalopathy (confusion, asterixis, altered sleep-wake cycle) when using hydroxyzine 13
Assess for precipitating factors of encephalopathy before each dose (constipation, infection, GI bleeding, electrolyte disturbances) and ensure patient is on appropriate lactulose therapy (2-3 soft stools daily) if any baseline encephalopathy exists, in patients with cirrhosis using hydroxyzine 13