Hydroxyzine (Atarax) Contraindications and Precautions
- benzyl alcohol hypersensitivity
- breast-feeding
- hydroxyzine hypersensitivity
- intraarterial administration
- intravenous administration
- neonatal prematurity
- neonates
- subcutaneous administration
- asthma
- bladder obstruction
- cardiac disease
- children
- chronic obstructive pulmonary disease (COPD)
- closed-angle glaucoma
- contact lenses
- dental work
- dialysis
- driving or operating machinery
- elderly
- ethanol intoxication
- GI obstruction
- glaucoma
- hepatic disease
- ileus
- infants
- labor
- pregnancy
- prostatic hypertrophy
- renal disease
- renal failure
- renal impairment
- surgery
- urinary retention
Hydroxyzine (Atarax) Contraindications and Precautions
Hydroxyzine is contraindicated for use in patients with a known hypersensitivity to the drug (hydroxyzine hypersensitivity) or to any of the formulation components. Also do not use this drug in patients with a known allergy to cetirizine, a known human metabolite of hydroxyzine. The injection may contain benzyl alcohol and may cause allergic reactions; avoid such preparations in patients with known benzyl alcohol hypersensitivity.
Parenteral hydroxyzine is for intramuscular (IM) administration only. Hydroxyzine is contraindicated for intravenous administration since IV administration can cause hemolysis, hypotension, cardiac or respiratory instability, or severe localized injection reactions (see Adverse Reactions). Subcutaneous administration or intraarterial administration are similarly to be avoided.
Clinical studies of hydroxyzine did not include sufficient numbers of elderly patients (>= 65 years old) to determine whether they respond differently to hydroxyzine than younger patients. Other reported clinical experience has not identified differences in response between elderly and younger patients. However, the elderly are generally more likely to experience anticholinergic or other CNS side effects of classic sedating antihistamines. Elderly patients should generally be started on low doses of hydroxyzine and closely observed, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Federal OBRA regulations recommend maximum dosage limits for anxiolytic and hypnotic use of hydroxyzine in the nursing home resident (see Dosage).
The anticholinergic activity of H1-blockers like hydroxyzine may result in thickened bronchial secretions in the respiratory tract thereby aggravating an acute asthmatic attack or chronic obstructive pulmonary disease (COPD). Although H1-antagonists should generally be avoided during an acute asthmatic attack, the use of H1-antagonists is not precluded in all asthmatic or COPD patients. Because histamine is known to be a bronchoconstricting substance in asthma, it is logical that antihistamines could reverse some of the harmful effects of histamine in patients with an allergic component to their asthma. Antihistamines are typically not contraindicated in asthma unless previous adverse reactions to the drugs have been observed.
Although cardiovascular effects of piperazine antihistamines like hydroxyzine are uncommon, H1-antagonists should generally be used conservatively in patients with cardiac disease. The quinidine-like local anesthetic and anticholinergic effects of some H1-antagonists are responsible for the adverse cardiac effects that have been observed including tachycardia, ECG changes, hypotension, and arrhythmias, particularly with overdosage.
Hydroxyzine should be used conservatively in patients with closed-angle glaucoma. Increased intraocular pressure may occur from the anticholinergic actions of the drug, precipitating an acute attack of glaucoma. Elderly patients are more susceptible to the anticholinergic effects of H1-antagonists, including possible precipitation of undiagnosed glaucoma. Other ocular effects resulting from the anticholinergic effects of hydroxyzine include dry eyes or blurred vision. This may be of significance in the elderly and wearers of contact lenses.
Because of the anticholinergic effects inherent to H1-antagonists like hydroxyzine, a worsening of symptoms may be seen in patients with bladder obstruction, GI obstruction or ileus, benign prostatic hypertrophy, or urinary retention. These precautions are most significant when using H1-antagonists from the ethanolamine and phenothiazine groups. The elderly are more susceptible to the anticholinergic effects of drugs since there is a decline in endogenous cholinergic activity that occurs with age.
Use hydroxyzine with caution in patients with renal disease. In moderate to severe renal impairment, prolongation of the drug half-life and reduced clearances of the drug and its metabolites occur. Neither hydroxyzine or cetirizine are appreciably removed during dialysis, and accumulation may occur in patients with renal failure. Dosage reduction of hydroxyzine may be necessary in patient populations with reduced renal function (see Dosage).
Hydroxyzine is extensively metabolized in the liver. Although hydroxyzine may be prescribed for patients with pruritus secondary to hepatic disease, the metabolism of hydroxyzine may be reduced in the presence of hepatic impairment. Hydroxyzine elimination is impaired in patients with primary biliary cirrhosis. Those with other significant hepatic disease should be monitored for side effects. Dosage adjustments may be required for those with hepatic disease.
The manufacturer of the drug considers use in the first trimester of pregnancy to be contraindicated (FDA pregnancy category X, first trimester). Limited evaluation of hydroxyzine during pregnancy indicates a possible relationship between the drug’s use in the first trimester and congenital abnormalities in the fetus; other studies have not concurred. No adequate studies exist for human pregnancy. Hydroxyzine is classified as FDA pregnancy risk category C for the second and third trimester. Hydroxyzine is sometimes given intermittently during labor or around the time of obstetric delivery to relieve anxiety, and is usually considered safe and effective for this purpose; however, occasional fetal heart rate variability might be observed. When used during labor and concurrently with narcotics, the narcotic requirement may be reduced as much as 50% and this reduction in needed narcotic therapy may be of benefit to mother and fetus. Use concurrent narcotics with caution to avoid hypotension.
The manufacturer recommends that hydroxyzine not be given during breast-feeding. It is unknown whether hydroxyzine is excreted into breast milk; however, the molecular weight of the drug is low enough that excretion into breast milk should be expected. The effects of the drug on the nursing infant are unknown. In general, many antihistamines are not recommended for use during lactation, since irritability, drowsiness, unusual excitement or other infant effects might be observed. Inhibition of lactation may be a possible side effect of first-generation antihistamines, secondary to anticholinergic effects.
Hydroxyzine may be used in children >= 2 years of age; safe and effective use in infants has not been established. Hydroxyzine may cause subjective somnolence in children, which may temporarily impair cognitive function. Paradoxically, hyperexcitability can occur in pediatric patients. Antihistamines should not be used in neonates or neonatal prematurity; these age groups are especially sensitive to anticholinergic effects and the use of antihistamines may increase the risk of CNS stimulation or convulsions. Furthermore, hydroxyzine injections may contain benzyl alcohol and should not be used in neonates (especially premature neonates) because benzyl alcohol has been associated with ‘gasping syndrome’, a potentially fatal condition.
Drowsiness has been reported with hydroxyzine; patients receiving this drug should be advised to avoid driving or operating machinery until the effects of the drug are known. Because the effects of ethanol or other CNS depressants may be additive with antihistamines, ethanol intoxication should be avoided while taking hydroxyzine.
Hydroxyzine is often used as an adjunct preoperatively. When hydroxyzine is used prior to dental work or surgery/perioperatively, the concurrent drug requirement of narcotics, non-narcotic analgesics or barbiturates may be reduced by as much as 50% to avoid hypotension or oversedation.
[ Last revised: 3/15/2004 11:00:00 AM ]
References
. Gurvich T, Cunningham JA. Appropriate Use of Psychotropic Drugs in Nursing Homes. Am Fam Physician 2000;61:1437 - 46.
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