Does Hydroxyzine Help With Xanax Withdrawal, and Can It Replace Xanax During a Taper?

Does hydroxyzine help with Xanax withdrawal?

Hydroxyzine is a sedating antihistamine. It can make a person drowsy, and some patients say that it helps them get through a rough night. It is indicated for anxiety, and it can ease anxiety for some people during a taper, but it does not treat the withdrawal itself from Xanax, or alprazolam, and it cannot take the place of Xanax.

The question usually comes up in one of two ways. A prescriber adds hydroxyzine during a taper to help with sleep. Or, a prescriber who has become uneasy about continuing Xanax stops the prescription and offers hydroxyzine in its place, because it is not a controlled substance.

Unfortunately, the second situation often rests on a mistaken idea about the patient. A person who has taken Xanax as prescribed, and who feels ill when a dose is late or reduced, has done nothing wrong. Physical dependence is not addiction. In fact, the United States Food and Drug Administration (FDA) stated in its 2020 boxed warning update that physical dependence can occur after several days to weeks of steady use, even as prescribed.

So, what is hydroxyzine, and why can it not do the job it is being handed?

Hydroxyzine is an antihistamine, and it is not a controlled substance.

Hydroxyzine belongs to the first generation of antihistamines, the older kind that cause drowsiness. It is sold by prescription as a generic and under the brand name Vistaril. Its FDA label lists the relief of anxiety and tension among its uses, and it describes the drug as chemically unrelated to the benzodiazepines.

It is not a scheduled drug, so it is simple to prescribe and simple to refill. Yet, that is a fact about paperwork. It says nothing about whether hydroxyzine can do what Xanax has been doing in the nervous system.

A separate article covers hydroxyzine for benzodiazepine withdrawal and tapering in general. This one is about Xanax, where the question is sharper.

Why can hydroxyzine not replace Xanax?

Xanax works by boosting gamma-aminobutyric acid (GABA), the brain’s main calming chemical. The Ashton Manual, written by Professor C. Heather Ashton, explains in its first chapter that all benzodiazepines act this way. With regular use the brain adapts to the extra help, and when the dose drops, it is left with less calming than it needs.

Hydroxyzine blocks histamine. It does nothing at the receptor where Xanax acts. Chapter III of the Manual says that no medication will substitute for a benzodiazepine unless it is another benzodiazepine or a drug with similar properties, and that antihistamines do not act by the same mechanisms.

So, a switch from Xanax to hydroxyzine is not a switch. It is an abrupt stop with a sedative added.

The FDA’s 2020 update warns that stopping a benzodiazepine abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, that can be life-threatening. Chapter III of the Manual ties fits to rapid withdrawal, especially from high-potency benzodiazepines. Table 1 in its first chapter rates Xanax at about twenty times the strength of Valium, or diazepam, milligram for milligram.

Hydroxyzine is not a seizure medication, and it offers no protection. The protection is a slow taper. With slow tapering, the Manual calls fits extremely rare. Call 911 for a seizure or any other medical emergency, and call or text 988, the Suicide and Crisis Lifeline, for thoughts of suicide.

Why is Xanax withdrawal often felt between doses?

Xanax is short-acting. The same table lists its half-life at six to twelve hours, against twenty to one hundred hours for diazepam. The amount in the blood rises and falls several times a day, and the Manual notes that people on short-acting benzodiazepines develop anxiety symptoms between doses.

That pattern is known as interdose withdrawal. A person can feel withdrawal every afternoon without having reduced the dose.

Think of a smoke alarm with a weak battery, chirping every few hours. Earplugs may let a person sleep through a chirp or two. They do not change the battery. Hydroxyzine is the earplugs.

Hydroxyzine adds drowsiness, but it does not change the falling blood level that causes interdose symptoms. The repair is at the battery, which means a steadier blood level first, and then a slow taper.

Why do some prescribers add hydroxyzine during a Xanax taper?

Because a hard night during a taper sends people looking for something to help with sleep, and a sedating antihistamine is close at hand. In Chapter III of the Ashton Manual, where Professor Ashton discusses sleep medication during withdrawal, she wrote that an antihistamine with sedative effects “may be used temporarily.” Her examples were two other sedating antihistamines of the same older generation. Hydroxyzine itself is not named.

The word to notice is “temporarily.” The hydroxyzine label points the same way, stating that its effectiveness for anxiety beyond four months has not been assessed.

While some patients do report a benefit, the evidence that hydroxyzine eases benzodiazepine withdrawal is limited, and benzodiazepine withdrawal is not among the uses on its label. The results are mixed. Some people sleep a little longer, and others have a groggy morning, a dry mouth, and anxiety that is still there underneath the drowsiness.

Individual response varies. For some people hydroxyzine eases anxiety or sleep during a taper, and short-term anxiety after one, but it does not allow larger reductions, and it does not shorten a taper.

What does the hydroxyzine label warn about?

The warning about heart rhythm comes first. The label states that hydroxyzine is contraindicated in patients with a prolonged QT interval, a delay in the heart’s electrical reset that shows on an electrocardiogram. It reports cases of QT prolongation and of torsade de pointes, a dangerous heart rhythm, and it advises caution with existing heart disease, electrolyte imbalances, and other medications that affect the QT interval.

A person in Xanax withdrawal may already have a pounding or racing heart. That is a reason to go over the heart history and the full medication list with the prescriber before hydroxyzine is added. Fainting, chest pain, or a fast, irregular heartbeat needs emergency care.

The label also lists dry mouth, an anticholinergic effect of the older antihistamines. It warns that sedating drugs may cause confusion and over-sedation in older adults, and it names early pregnancy as a contraindication.

Can hydroxyzine and Xanax be taken together?

They are sometimes prescribed together, and the label’s caution about sedation applies. It warns against driving or operating machinery, says that the effects of alcohol may be increased, and advises patients against taking other drugs that depress the central nervous system at the same time, because hydroxyzine strengthens their effect. Xanax is one of them.

The Manual’s first chapter lists sedative antihistamines among the drugs whose effects add to those of a benzodiazepine. So, the drowsiness adds up and reactions slow, and the heaviness can last into the next morning.

Whether to combine them is a decision for the person’s own prescriber, who needs the full medication list. The pharmacist should have it as well.

Fortunately, the Ashton Manual has an answer for Xanax.

It is in Chapter II. With a short-acting benzodiazepine such as Xanax, Professor Ashton wrote, a smooth decline in blood and tissue levels is not possible. She advised a gradual switch, one dose at a time, to diazepam, whose slow elimination lets the level fall smoothly.

That switch is the crossover taper, and another article explains the move from Xanax to Valium. It works because diazepam acts at the same receptor as Xanax, and hydroxyzine cannot stand in for it. Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, uses the crossover where it helps.

With or without a crossover, the shape of the taper is the same: a small reduction, a short hold while the person settles, then the next small reduction. On alprazolam, a hold that does not settle within a few weeks is a reason to talk with the prescriber about a crossover to diazepam or continuing the taper, planned together and never by stopping suddenly, rather than waiting indefinitely. The Manual suggests steps of up to one tenth of the dose, with the patient in control of the pace. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which the steps get smaller as the dose gets lower.

A taper like this often takes a year to 18 months or longer, depending on the starting dose and how long the medication has been taken. The FDA’s 2020 update says that no standard tapering schedule suits every patient, so the plan is built with the prescriber and revised as the body reports back.

How are decisions about hydroxyzine made in Dr. Leeds’ practice?

Questions about antihistamines, supplements, and other remedies are settled one patient at a time, with a physician who understands the pharmacology. Whether hydroxyzine has any part in a given taper depends on the person’s heart, age, other medications, and how the taper itself is going. Dr. Leeds uses it in his practice where it can help, after screening for heart conditions that rule it out. There is no blanket rule and no standard dose, which is why no dose appears in this article.

After a run of bad nights following a reduction, a common first question is whether the last step was too large. A short hold, or a slower pace from there, is a common answer, though everybody is different, and a hold that does not settle within a few weeks is a reason to talk about the next step rather than to wait indefinitely. Any added medication calls for informed consent: the risks first, the alternatives, including no added medication at all, a plan for stopping, and the right to decline.

Dr. Leeds’ practice provides medically supervised tapering of benzodiazepines and z-drugs, the related sleep medications, for patients in Florida. He works directly with each patient, and the taper is gradual, patient directed, and adapted to the person. Contact the office to ask about a gradual taper from Xanax.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.