Hydroxyzine in Hospice and Palliative Care: An In-depth Exploration and Key Considerations.
The application of hydroxyzine in hospice and palliative care emphasizes the value of tailored care plans.
Hydroxyzine is a versatile medication belonging to the class of antihistamines, although its applications and use extend beyond allergy relief. In this article, we will delve into the drug class of hydroxyzine, its dosage forms, common uses, and potential side effects, and explore its role in hospice and palliative care.
Overview of Hydroxyzine:
Hydroxyzine belongs to a class of medications known as first-generation antihistamines, which means it primarily targets histamine receptors in the body. Besides its antihistamine properties, hydroxyzine also possesses anticholinergic and sedative effects. An anticholinergic effect is a physiological effect caused by the inhibition or blockade of the neurotransmitter acetylcholine at its receptors, which leads to effects that are widespread throughout the body and impact various organ systems. These attributes of hydroxyzine contribute to its usefulness in a wide array of medical situations.
Dosage Forms of Hydroxyzine:
Hydroxyzine is available in various dosage forms, including oral tablets, capsules, oral solutions, and intramuscular injections. The choice of form depends on the specific medical condition being treated and the desired onset of action.
Side Effects of Hydroxyzine:
While hydroxyzine is mostly well-tolerated, it may cause side effects in some individuals. Common side effects include the following.
Dry Mouth: Inhibition of salivary gland activity leads to reduced saliva production, resulting in a dry sensation in the mouth.
Blurred Vision: Anticholinergic drugs such as hydroxyzine can affect the muscles in the eye, leading to impaired accommodation and blurred vision.
Constipation: Reduced gastrointestinal motility can occur because of the anticholinergic effect of hydroxyzine, leading to constipation.
Urinary Retention: Anticholinergics medications like hydroxyzine can cause smooth muscle contraction in the urinary bladder to decrease, leading to difficulty in emptying the bladder fully.
Confusion and Cognitive Impairment: Anticholinergic drugs like hydroxyzine can cross the blood-brain barrier and affect central nervous system function, potentially causing confusion, memory impairment, and cognitive disturbances.
Increased Heart Rate: Inhibition of acetylcholine on the heart can lead to an increase in heart rate.
Dilated Pupils (Mydriasis): Anticholinergic drugs like hydroxyzine can cause the pupils to dilate by inhibiting the constriction of the iris sphincter muscle.
Reduced Sweating: Inhibition of acetylcholine in sweat glands may result in reduced sweating, leading to potential issues with temperature regulation.
Less frequently, hydroxyzine may lead to more serious side effects such as allergic reactions, irregular heartbeats, or seizures. Closely monitoring our patients and providing immediate medical attention is crucial if any adverse reactions occur.
Indications for the use of Hydroxyzine:
Allergic Conditions: Prescribers commonly prescribe hydroxyzine, an anticholinergic to palliate symptoms associated with allergic conditions, such as itching, hives, and allergic rhinitis.
Anxiety and Sedation: Although not recommended as first-line therapy for the management of anxiety disorder, because of the sedative effects of hydroxyzine, it is sometimes used to manage anxiety disorders and as a preoperative sedative.
Insomnia: The sedative properties of Hydroxyzine make it a potential option for treating short-term insomnia.
Nausea and vomiting: In certain cases, prescribers may prescribe hydroxyzine to help relieve nausea and vomiting.
Use of Hydroxyzine in Hospice and Palliative Care:
Medical professionals have increasingly recognized the role of hydroxyzine, a first-generation antihistamine with additional sedative properties, in hospice and palliative care settings. The use of hydroxyzine in these contexts is focused on addressing specific symptoms and improving the overall quality of life for individuals nearing the end of life. The following is an analysis of hydroxyzine use in hospice and palliative care.
Symptom Management:
· Anxiety and Agitation: Hydroxyzine’s sedative effects make it beneficial in managing anxiety and agitation, common symptoms experienced by individuals in hospice and palliative care. The calming properties of hydroxyzine can contribute to a sense of comfort and tranquility for this patient population.
· Insomnia: Many patients in hospice care may have trouble sleeping. Hydroxyzine’s sedative properties can help induce and maintain sleep, promoting rest and overall well-being.
· Itching: Hydroxyzine is an antihistamine medication commonly used to relieve itching. It works by blocking the effects of histamine, a natural substance in the body that contributes to itching, sneezing, and runny nose.
Route of Administration:
Hydroxyzine is available in various forms, including oral tablets, capsules, and oral solutions. The choice of administration depends on the patient’s ability to swallow, absorb medications, and the urgency of symptom relief. When oral administration is not feasible, in some cases, healthcare providers may consider using intramuscular injections of hydroxyzine for prompt relief.
Safety Profile of Hydroxyzine:
Hydroxyzine is a safe medication, especially when compared to some other sedatives like benzodiazepines and others that are sometimes used in hospice and palliative care. It has a lower risk of respiratory depression, which is a crucial consideration in the care of individuals with advanced illnesses. Although hydroxyzine is well-tolerated by many patients, healthcare providers should be vigilant for potential side effects, especially in vulnerable populations such as older adults.
Individualized Care:
The application of hydroxyzine in hospice and palliative care emphasizes the value of tailored care plans. When establishing the suitable dosage and route of administration, it is vital to take into consideration the unique symptoms, preferences, and medical history of each patient. Regular assessments and adjustments may be necessary to ensure optimal symptom management without undue sedation or adverse effects.
Multimodal Approach:
Prescribers sometimes consider Hydroxyzine as part of a multimodal approach to symptom management in hospice and palliative care. This may involve combining hydroxyzine with other medications or non-pharmacological interventions to address a range of symptoms, including pain, nausea, and psychological distress.
Consideration of comorbid conditions:
Hydroxyzine’s anticholinergic effects, while generally mild, should be considered, especially in individuals with pre-existing conditions, such as urinary retention or constipation. Adjustments to the care plan may be necessary to mitigate these effects.
Ethical and Legal Considerations:
Incorporating hydroxyzine into hospice and palliative care practices is consistent with ethical values that prioritize offering comfort, preserving dignity, and showing respect to those nearing the end of their lives. To ensure proper use of hydroxyzine or any other medication in palliative care, it is crucial to follow local regulations and guidelines.
Difference Between Hydroxyzine Hydrochloride and Hydroxyzine Pamoate:
Hydroxyzine is available in two main formulations: hydroxyzine hydrochloride and hydroxyzine pamoate. The primary difference lies in their solubility and pharmacokinetics. Hydroxyzine hydrochloride (Atarax) exhibits water solubility and finds common usage in oral tablet and solution forms. On the other hand, Hydroxyzine pamoate (Vistaril) is soluble in lipids and commonly appears in capsule form.
Some prescribers lean towards the hydrochloride salts as an antihistamine to treat itching while leaning towards the Pamoate to treat anxiety and sleep disorder. Although there is not enough evidence to support the use of one particular salt over the other to treat a specific disorders, these preferences by prescribers follow the notion that hydroxyzine Pamoate’s lipid solubility allows the drug to readily cross the blood-brain barrier and treat disorders of the brain and the central nervous system, while what soluble Hydroxyzine hydrochloride will not easily cross the blood-brain barrier, as such, will better serve as an antihistamine.
The major, and only differences at this point between the hydrochloride and pamoate salts in hydroxyzine, are the various dosage forms and costs. Hydroxyzine hydrochloride is available as tablets, syrup, and solution for intramuscular injection, although the tablets are frequently used in the hospice and palliative care setting. Hydroxyzine pamoate is only available in capsule form. Also similar in mechanisms of action, dosing recommendations, and labeled indications, hydroxyzine hydrochloride tablets cost significantly higher than hydroxyzine pamoate capsules.
References:
1. Guaiana G, Barbui C, Cipriani A. Hydroxyzine for generalized anxiety disorder. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD006815. doi: 10.1002/14651858.CD006815.pub2. PMID: 21154375.
2. Atarax is for Itch, and Vistaril is for anxiety. Pharmacist’s Letter. 2021. Accessed January 6, 2024. https://pharmacist.therapeuticresearch.com/Content/Articles/PL/2005/Dec/i-Atarax-i-is-for-itch-and-i-Vistaril-i-is-for-anxiety.
3. Hydroxyzine Hydrochloride. Package Insert. Teva Pharmaceuticals USA Inc.; 2016. Accessed January 8, 2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=80309ec1-e5d5-4454-b8ce-67d7e6805e44.
4. Hydroxyzine Hydrochloride. Package Insert. Teva Pharmaceuticals USA Inc.; 2016. Accessed January 6, 2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=80309ec1-e5d5-4454-b8ce-67d7e6805e44.
Fidelis Ariguzo - PharmD, RPH | PDC Rx