Hydroxyzine (Vistaril®) versus Alprazolam (Xanax®)

Based on "Essential Psychopharmacology"
written by Stephen M. Stahl, MD, PhD

Difference between Hydroxyzine and Alprazolam chart

From the comparison chart below you can see what is common and what is different between the two medications:

Hydroxyzine	Alprazolam
• Atarax® (hydroxyzine hydrochloride) • Vistaril® (hydroxyzine pamoate)	• Xanax ® • Xanax XR®
• Both Vistaril® and Xanax® are marketed by Pfizer in the United States
Drug class
• First generation H1 antihistamine of piperazine class • Has anxiolytic, sedative, antiemetic, and anticholinergic properties.	• Benzodiazepine, high-potency, short/intermediate acting • Has anxiolytic, sedative, anticonvulsant, and muscle relaxing properties.
Dose formulations
• Tablets • Capsules • Oral suspension • Injectable solution	• Tablets • Tablets, extended-release • Tablets, orally disintegrating • Oral solution
Legal status
• Prescription only
• Not controlled drug	• Controlled substance, Schedule IV
FDA-approved indications
• Symptomatic relief of anxiety , tension, and agitation • Pruritus due to allergic reactions, atopic or contact dermatitis. • Premedication sedation • Sedation following general anesthesia • Acute behavioural disturbance, acute hysteria (intense anxiety) (injection only) • Anxiety during withdrawal from alcohol (injection only)	• Anxiety disorder • Panic attacks
"Off-label" uses
• Insomnia
• Vomiting • Nausea • Severe behavioral problems • Sleep disorders in children	• Premenstrual syndrome • Depression • Dental and surgical procedures to relax the patient1 • Decrease withdrawal symptoms during withdrawal from alcohol and sedative-hypnotic drugs
Mechanism of action
• Hydroxyzine blocks H1 antihistamine and muscarinic receptors. • Sedative and anxiolytic effects result principally from suppression of activity at subcortical levels of the CNS.	• Alprazolam works by stimulating the action of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS.
Half-life
• 20 hours in adults • 7 hours in children	• 11.2 hours
Oral bioavailability
• 80%	• 90%, well-absorbed orally
Metabolism, Elimination
• Hydroxyzine is excreted in feces via biliary elimination. • Metabolism of hydroxyzine in extensive and mainly hepatic. The drug is rapidly converted to it major metabolite cetirizine.	• Alprazolam is metabolized by the liver, primarily by cytochrome CYP3A4. It is metabolized to two major metabolites: 4-hydroxyalprazolam and α-hydroxyalprazolam. • Alprazolam and its metabolites are excreted primarily by kidneys and some via feces.
Contraindications
• First trimester of pregnancy • Hypersensitivity to hydroxyzine, cetirizine, or other piperazine derivatives • Porphyria • Pre-existing prolonged QT interval	• Concomitant use with CYP3A4 inhibitors (e.g. itraconazole, ketoconazole) • Hypersensitivity to benzodiazepines • Acute narrow angle glaucoma
Warnings & precautions
• Depression of CNS function • Daytime sedation • Alcohol can intensify the nervous system side effects of both alprazolam and hydroxyzine
• Rare cases of acute generalized exanthematous pustulosis (AGEP) have been reported • QT prolongation/torsades de pointes • Oversedation in elderly people	• Risk of dependence • Tolerance - long term use leads to tolerance and reduced therapeutic effect • Withdrawal symptoms upon discontinuation of a drug • Amnesiac effects - high benzodiazepine doses may cause amnesia
Side effects
• Drowsiness • Somnolence • Dry mouth • Fatigue • Bitter taste in the mouth • Headache • Side effects of hydroxyzine are mild and transitory in nature	• Drowsiness • Sedation • Somnolence • Fatigue • Weakness • Lightheadedness • Memory impairment, confusion • Impaired motor coordination
Pregnancy category
• Pregnancy category is not assigned • Hydroxyzine is contraindicated in early pregnancy	D

Hydroxyzine advantages over Alprazolam

Is Hydroxyzine better than Alprazolam?

• Hydroxyzine is not a controlled substance and is not habit forming drug. Antihistamine does not cause withdrawal symptoms and does not produce memory impairment.
• Unlike alprazolam hydroxyzine has an antiemetic activity.
• Like with benzodiazepines, hydroxyzine anti-anxiety effects occur quickly.

Alprazolam advantages over Hydroxyzine

Is Alprazolam better than Hydroxyzine?

• Alprazolam is a better anti-anxiety medication than hydroxyzine1.
  

Further reading

• Alprazolam (Xanax) vs Lorazepam (Ativan)
• Alprazolam (Xanax) vs Zolpidem (Ambien)

References

• 1. Franssen C, Hans P, Brichant JF, Noirot D, Lamy M. Comparison between alprazolam and hydroxyzine for oral premedication. Can J Anaesth. 1993 Jan;40(1):13-7.
• 2. VISTARIL® (hydroxyzine pamoate) Pfizer. Available PDF
• 3. Xanax (Alprazolam) Prescribing Information

Published: July 07, 2018
Last updated: July 07, 2018