Hydroxyzine side effects in elderly patients

Common Hydroxyzine side effects | Serious side effects | Side effects timeline | Interactions | How to avoid side effects | How to treat side effects

Hydroxyzine is an antihistamine primarily prescribed for the relief of pruritus (itching) and anxiety. Older adults need to be cautious with this drug due to its side effects. Learning more about the potential for adverse reactions to hydroxyzine or its brand name version, Vistaril, should prepare you to discuss with your healthcare provider whether to take it and how to mitigate any risks. 

Common side effects of hydroxyzine 

Hydroxyzine hydrochloride has a few common and relatively mild side effects, but it also has some serious ones. Looking out for these adverse reactions is important, especially since their incidence rate is not listed on the drug’s label due to its approval from the Food and Drug Administration (FDA) years ago.

Physical side effects of hydroxyzine in the elderly

The common physical adverse effects of hydroxyzine are not extensive. They can still be troublesome, though, and require medical assistance if severe or persistent. Physical side effects include the following:

• Dry mouth
• Headache
• Skin rash
• Allergic reaction
• Tremor

Cognitive side effects of hydroxyzine in the elderly

Older adults tend to be more susceptible to the side effects of hydroxyzine. Drowsiness and difficulty thinking are fairly common and warrant the advice of your healthcare prescriber regarding what to do if they occur.

Emotional and psychological side effects of hydroxyzine in the elderly

Mood changes and psychological fallout of hydroxyzine use are noteworthy as well. These include agitation and hallucinations, which can be quite disturbing. Notify your healthcare provider if you experience either.

Serious side effects of hydroxyzine 

Serious side effects of hydroxyzine include:

• QT prolongation, also called long QT syndrome
• Torsades de Pointes heart arrhythmia
• Seizures
• Respiratory depression

How soon do hydroxyzine side effects start?

The onset time for hydroxyzine side effects is quite variable. For example, drowsiness can occur within an hour of a dose. On the other hand, the onset of QT prolongation or respiratory depression may not occur until another drug with overlapping possible side effects is taken with hydroxyzine.

How long do hydroxyzine side effects last?

Most of the adverse effects of hydroxyzine will last as long as you continue to take the medication. Dry mouth is one such side effect. Mild drowsiness, however, could subside with continued use, but you should be cautious and check with your healthcare provider about whether to continue it.

What are the long-term side effects of hydroxyzine?

QT prolongation, which consists of changes in the electric conductivity pattern of the heart, is the most substantial long-term side effect of hydroxyzine, and it is one that you may not even feel until it triggers a life-threatening, abnormal heart rhythm. Fortunately, if you are at higher potential risk, you can be checked for QT prolongation by having an electrocardiogram (ECC or EKG). Another bit of good news is that QT prolongation induced by hydroxyzine can be reversed by discontinuing the drug.

Hydroxyzine interactions

Hydroxyzine can interact in a very significant way with a number of drugs. Older patients need to be on high alert for this potential if they take other medications that put them at higher risk. The interactions include the following:

• Central nervous system (CNS) depressants impair brain function, typically causing drowsiness. The potential exists for respiratory depression (less natural drive to breathe). CNS depressants include sub-classes such as opioids, benzodiazepines, antihistamines, drugs for insomnia, and anticonvulsant medications.
• QT-prolonging drugs also have additive side effects; taking two or more medications with this adverse effect can compound the hazard of an irregular heartbeat. Many different types of drugs can prolong the QT interval, but common examples include macrolide antibiotics, quinolone antibiotics, antipsychotics, and antidepressants.
• Anticholinergic drugs include multiple classes of drugs, such as muscarinic antagonists, antipsychotics, and tricyclic antidepressants. It is also a category that can be particularly dangerous for older patients, more so with the use of hydroxyzine concurrently. Side effects include dry mouth, blurred vision, difficulty urinating, constipation, confusion, and agitation.
• Alcohol and cannabinoid products are also CNS depressants that can heighten the hazards of hydroxyzine.
• Grapefruit juice can impair the metabolic clearance of hydroxyzine, leading to the accumulation of higher drug levels in the body and, consequently, more adverse effects.

Safety measures while using hydroxyzine

Drug interactions are not the only thing to be cautious of when taking hydroxyzine. Although there are no boxed warnings on the drug’s FDA label, there are cautionary notes about how hydroxyzine can be more troublesome in certain settings and with some health conditions.

Hydroxyzine and kidney disease

Kidneys eliminate hydroxyzine from the body, so naturally, if kidney function is reduced, the drug tends to hang around in the body longer and accumulate. This could lead to more adverse effects for anyone with kidney disease, something that is more prevalent among seniors. Ask your doctor about your kidney function and for medical advice about whether your dose needs to be reduced.

Hydroxyzine and glaucoma

The anticholinergic effects of hydroxyzine can trigger an exacerbation of narrow-angle glaucoma. If you have that form of glaucoma, you should ask your eye care provider about what medications to avoid.

Hydroxyzine and prostatic hypertrophy

Prostate enlargement, a condition that can obstruct urine flow, affects men as they age. Considering that medications with anticholinergic effects, like hydroxyzine, can lead to urinary retention, older men should be leery of taking the drug. Adding hydroxyzine on top of an enlarged prostate could trigger urinary retention, or the inability to urinate, in men.

Hydroxyzine and herbal supplements

Herbal remedies can fall into categories that are known to interact with hydroxyzine. CNS depressants like kratom, anticholinergics like Jimson weed, and QT-prolongers like berberine are examples of this potential.

Hydroxyzine and overdose

Hydroxyzine is not considered habit-forming or prone to withdrawal upon discontinuation, but it can be very dangerous in the setting of overdose. Besides drowsiness and nausea, an overdose of hydroxyzine can lead to seizures or respiratory depression. An overdose of this drug can be a medical emergency that should prompt a call to 911 as well as to Poison Control at 1-800-222-1222.

How to avoid hydroxyzine side effects

You can reduce the risk of hydroxyzine side effects by doing the following:

1. Follow the hydroxyzine prescription instructions for dose and interval, being sure to avoid taking too much and taking it too often.
2. If the medication is only ordered for as-needed usage, you do not have to take it regularly and can wait until you have symptoms.
3. Regularly review your list of prescription drugs, over-the-counter medications, and supplements with your healthcare provider and pharmacist, especially prior to starting hydroxyzine.
4. Be sure to go over your list of medical conditions with your healthcare provider and double-check with them prior to taking hydroxyzine if you have glaucoma, kidney problems, breathing problems, or prostate enlargement.
5. If more expensive alternatives to hydroxyzine exist and the cost is holding you back from changing, consider using hydroxyzine coupons, which you can get with a SingleCare pharmacy discount card.

How to treat side effects of hydroxyzine

Common side effects like mild drowsiness or dry mouth may resolve by reducing the dose of hydroxyzine or discontinuing it. Very serious side effects like seizures, irregular heartbeat, and respiratory depression should trigger emergency medical attention.

Bottom line: Is hydroxyzine safe for older adults?

Hydroxyzine’s adverse effects and drug interactions do not line up well for use in older adults. The risks of the medication are simply greater in this age group. Emphasizing the dangers involved, the American Geriatric Society included hydroxyzine on its list of potentially inappropriate medications for older people. With that in mind, consult your healthcare team about whether an alternative is available.