Atarax/Visteril

cbrons

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    What is it about this drug that makes it an effective anxiolytic?

    How does it compare to Benedryl in terms of its sedating effect?

    What dosing schedule is reasonable to start for anxiety, and whats reasonable for treatment of insomnia in inpatients who you dont want to give benzodiazepines?
     

    Shikima

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      The way I discuss it is that it is a cousin to Benadryl. Not sure how anything works for antidepressant/antianxiety when it comes to the brain. Dosing is the same as Benadryl, same side effects effectively. I consider it to be sedating, titrate to effect by starting with one. Those that don't get sleepy from it can use it during the daytime.
       
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      st2205

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        Some people may try to get ultra technical about different mechanisms outside the obvious, but people tend to equate anything sedating with 'treating' anxiety. I have found, however, that people who are quite anxious by nature and sensitive to effects of medications or feeling sedated, that they seem to do reasonably well with 10 mg. But people can certainly use it on patients in higher, more standard doses as an alternative to benzos to treat their own anxiety about the patient.
         
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        DisorderedDoc417

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          Mechanism of action: Anxious patient --> *takes anti-histamine* --> sedated anxious patient --> Happy nurses --> Less pages at 3AM --> Happy doctors --> UPTODATE editors --> "Anti-histamine efficacious for anxiety"
           
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          WisNeuro

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            Vistaril has substantially less anticholinergic effects than benadryl.

            Less then benadryl, more than many other anticholinergic agents. Last I checked, it was still ranked as high on any ACB type of scale. Also, patients are usually on at least two drugs with anticholinergic effects, an anxiolytic, and possibly an opiate and/or tranq for sleep.
             

            hamstergang

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              Less then benadryl, more than many other anticholinergic agents.
              What source are you using for this? The receptor affinity I'm finding for hydroxyzine on mAch is rather close to negligible, especially in comparison to its H1 blockade. This wiki article lists 5 sources supporting this: Hydroxyzine - Wikipedia
               

              WisNeuro

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                What source are you using for this? The receptor affinity I'm finding for hydroxyzine on mAch is rather close to negligible, especially in comparison to its H1 blockade. This wiki article lists 5 sources supporting this: Hydroxyzine - Wikipedia

                Anti-cholinergic Burden Scale, Magellan Anticholinergic Risk scale, Beers Criteria, listed as high risk through Medica, and just about every polypharm in geriatric article I have seen. I personally see Benadryl as more often the cause of delirium, but there are a lot of sources that have hydroxyzine as high on the list. If that's not the case, a lot of these sources need to change their lists.
                 

                nitemagi

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                  Anti-cholinergic Burden Scale, Magellan Anticholinergic Risk scale, Beers Criteria, listed as high risk through Medica, and just about every polypharm in geriatric article I have seen. I personally see Benadryl as more often the cause of delirium, but there are a lot of sources that have hydroxyzine as high on the list. If that's not the case, a lot of these sources need to change their lists.
                  I think there's very little evidence in the primary literature to support those claims.
                  Comparative anticholinergic activities of 10 histamine H1 receptor antagonists in two functional models. - PubMed - NCBI
                  Antimuscarinic effects of antihistamines: quantitative evaluation by receptor-binding assay. - PubMed - NCBI
                  Prediction of drug-induced catalepsy based on dopamine D1, D2, and muscarinic acetylcholine receptor occupancies. - PubMed - NCBI
                   

                  WisNeuro

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                    I would suggest that you then e-mail the authors of all of the anticholinergic burden scales and the beers criteria with your concerns, then. While you guys get that sorted out, I will still point it out on my "consider limiting the use of anticholinergic/opiate/anxiolytic" recommendations in my elderly patients.
                     

                    hamstergang

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                      I would suggest that you then e-mail the authors of all of the anticholinergic burden scales and the beers criteria with your concerns, then. While you guys get that sorted out, I will still point it out on my "consider limiting the use of anticholinergic/opiate/anxiolytic" recommendations in my elderly patients.
                      What's with this attitude of feeling those anticholinergic burden scale makers are beyond fault and ignoring sources that look directly at the question? I'm a little surprised you seem so set on continuing in your path and so uninterested in investigating the actual research.
                       
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                      WisNeuro

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                        What's with this attitude of feeling those anticholinergic burden scale makers are beyond fault and ignoring sources that look directly at the question? I'm a little surprised you seem so set on continuing in your path and so uninterested in investigating the actual research.

                        I do not hold them above fault. But, I just don't have the time to independently verify the >100 medications on the lists, so I err on the side of caution, especially considering that anti-anxiety medications just do not work in the long term and in general make things worse. Additionally, if we always assumed that medication studies on pig tracheas and rats worked the same in humans, we would have a much different medication landscape. I've done bench work in the past. I'd actually just like to see more compelling research before I change my recommendation parameters.
                         

                        hamstergang

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                          I do not hold them above fault. But, I just don't have the time to independently verify the >100 medications on the lists, so I err on the side of caution, especially considering that anti-anxiety medications just do not work in the long term and in general make things worse. Additionally, if we always assumed that medication studies on pig tracheas and rats worked the same in humans, we would have a much different medication landscape. I've done bench work in the past. I'd actually just like to see more compelling research before I change my recommendation parameters.
                          We're talking about 1 medication. Where is the evidence that this 1 medication contributes to delirium or is even anticholinergic?

                          I'm trying to go through the sources the scales are based on to see where they got the idea that hydroxyzine is a problem, but it's difficult on my phone without access to all these articles. So far, however, I haven't found any source that actually shows hydroxyzine to be deliriogenic (that's a word, right?).
                           

                          WisNeuro

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                            One of the articles posted does state that it has anticholinergic properties, just below those of something like diphenhydramine. Even without the possible anticholinergic effects, the sedating effects can present as confusional/poor attention in the elderly. All in all, we have better ways of treating anxiety in the elderly without the risk. I see recommendations against its use as high upside, low downside, for a variety of reasons.
                             

                            hamstergang

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                              One of the articles posted does state that it has anticholinergic properties, just below those of something like diphenhydramine. Even without the possible anticholinergic effects, the sedating effects can present as confusional/poor attention in the elderly. All in all, we have better ways of treating anxiety in the elderly without the risk. I see recommendations against its use as high upside, low downside, for a variety of reasons.
                              Yeah, 2 articles stated it had low affinity for mAch receptors (far below its H1 affinity), and 1 stated it had no in vivo anticholinergic activity (and you already basically stated you don't care as much about measured receptor activity as actual action in humans). This whole train of discussion started because you stated it had "large anticholinergic effects." This has now been debunked. No need to set up new goal posts.
                               

                              WisNeuro

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                                I wouldn't call it "debunked" based on the available information as of yet provided. Translational studies have been woefully different between animal models and actual human interaction before. I am willing to reconsider my position, just not based on this particular information. It's a starting point, not a definitive answer. My goal posts remain in the same position.
                                 

                                nitemagi

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