13 Comparison between alprazolam and hydroxyzine for oral C. Franssen Mo, R Hans MO, J.E Brichant Mo, D. Noirot Mr), M. Lamy Mo premedication

The safety and efficacy of alprazolam and hydroxyzine ad- viduellement le degrd d'anxi~t~: le patient utilise une ~chelle ministered orally as surgical premedicants were compared in visuelle analogique alors que l'anesth~siste utilise une classi- a double-blind controlled study. Sixty-five patients were given fication ordinale en plus de l~chelle analogique. Grace ~ ces either alprazolam 1 mg or hydroxyzine 75 mg, one to two deux m~thodes, le sddation fait l'objet d'un ~valuation par hours before surgery. Anxiety was assessed by both the patient l'anesth~siste seul. L'amndsie est estim~e par une test de and the anaesthetist, the patient using a visual analogue scale, m~moire simple. On ~value la s~curit~ des m~dicaments par the anaesthetist employing both analogue and ordinal ratings. l'enregistrement des effets d~favorables et la mesure des variables Sedation was assessed by the anaesthetist only, using the same h~modynamiquea. La pr~mddication gt l'alprazolam produit two methods. Amnesia was appraised with a simple memory une baisse modeste de l'anxi~t~ (28%) (P < 0,01) alors que test. Safety was assessed by recording adverse effects and meas- lT~ydroxyzine ne produit pas d'effets d~celables. La comparaison uring haemodynamic variables. Premedication with alprazolam entre les deux pr~m~dications pour le degr~ de s~dation et le produced a modest reduction in anxiety (28%) (P < 0.01) while test de mdmoire ne rdvble pas de difference. Des effets secon- hydroxyzine had no detectable effect. The comparison of the daires mmeurs ne sont observes Clue dans le groupe hydro- sedation level and of the memory test revealed no difference xyzine. Les changements tensionnels sont plus prononc~s darts between the two premedicants. Minor side effects were only ce dernier groupe. Cette dtude d$montre que l'alprazolam et observed in the hydroxyzine group. Changes in blood pressure I'hydroxyzine sont en prdm~dication des m~dicaments ss et were more pronounced in the hydroxyzine group. This study efficaces. Cependant l'alprazolam eat sup~rieur ~ l'hydroxyzine shows that alprazolam and hydroxyzine are safe and efficient sous l'aspect de l'anxiolyse et des effets secondaires. oral premedicants. However, alprazolam is preferable to hy- droxyzine in terms of anxiolytic and adverse effects. The most common reasons for administering pre- Au cours d'une dtude ~ double insu, on compare la sdcuritd anaesthetic medication are to relieve anxiety and to et l'efficacitd de l'alprazolam et de l'hydroxyzine administrds reduce awareness related to surgery. Premedicants are ex- par voie orale en prdmddication. Soixante-six patients refoivent pected to allow the patient to enter the operating room alprazolam 1 mg ou hydroxyzine 75 mg de une ~ deux heures with minimal apprehension, sedated but easily rousable, avant la chirurgie. Le patient et l'anesthdsiste dvaluent indi- and cooperative without uncomfortable side effects. A major advantage of oral premedication is to avoid painful injection. Benzodiazepines are used extensively as oral premedicants. They are effective in producing anx- Key words iolysis and amnesia, and are associated with good patient ATARACTICS:hydroxyzine; acceptance. 2,3 The efficacy and safety of alprazolam HYPNOTICS: alprazolam, hydroxyzine, benzodiazepines; (xanax| a new triazolobenzodiazepine, are well docu- PREMED1CATION:alprazolam, hydroxyzine. mented. 4,5 It was found to have the following properties: From the Department of Anaesthesiology,University Hospital major anxiolysis, minor respiratory depression and a low of Litge, B35, Domaine Universitaire du Sart Tilman, B-4000 incidence of drowsiness. After oral administration, it is Litge, Belgium. rapidly absorbed and has a serum half-life of 12 to 15 Address correspondence to: Dr C. Franssen, Department of hr following a single oral dose. Because of these char- Anaesthesiology,University Hospital of Litge (B35), B-4000 acteristics, alprazolam can be considered as a potential Sart Tilman Litge. presurgical medication. Hydroxyzine (Atarax| is an Supported by a grant from Upjohn Benelux, Puurs, unique non-phenothiazine tranquilizer which has bron- Belgium. chodilator, anthihistaminc and analgesie effects. It has Accepted for publication 19th September, 1992. been found to be an effective surgical premedicant.6

CAN J ANAESTH 1993 / 40:1 / pp 13-7 14 CANADIAN JOURNAL OF ANAESTHESIA

The present study was designed to compare the efficacy Safety was evaluated based on the global assessment and safety of alprazolam and hydroxyzine as oral pre- of the tolerance by the patient, the adverse effects reported medicants. and the evolution of vital signs (blood pressure (BP), heart rate (HR), respiratory rate (RR)) during the period Methods of study. To express global acceptance, each patient was After approval by the Hospital Ethical Committee and requested to qualify the premeditation as satisfactory, un- informed consent from each patient had been obtained, satisfactory or indifferent; no specific question was asked 65 ASA I-II patients, ages 16 to 65 yr and scheduled to the patient. All adverse signs and symptoms reported for plastic or orthopaedic surgery were included in this by the patient to the anaesthetist on the evening after randomized, double-blind study. Use of anxiolytic or sed- surgery or observed by the anaesthetist in the operating ative drugs, alcohol addiction, renal or hepatic insuffi- room and in the recovery room were noted. Vital signs ciency, myasthenia and intolerance or hypersensitivity to were recorded by the anaesthetist at Ti, T 2 and T 3. benzodiazepines or hydroxyzine were considered as ex- clusion criteria. Statistical analysis Thirty-four patients (52%) were given alprazolam 1 mg All statistical tests carried out were two sided at the 5% and 31 patients (48%) received hydroxyzine 75 mg orally level of significance. Discrete variables were compared one to two hours before induction of anaesthesia. Patients on the basis of the chi-square test (two by two tables) did not receive any other sedative or hypnotic drug either or the Fisher exact test (small frequencies). Continuous the evening before or during the day of surgery. Anaes- variables were compared using the t test for independent thesia was induced with propofol (2 mg" kg -I) and su- samples and the Mann-Whitney test. The VAS assess- fentanil (0.1-0.2 ~tg- kg -l) and muscle relaxation was pro- ment in the two groups were compared using repeated duced with atracurium (0.5 mg. kg-t). Maintenance of measures analysis of variance (ANOVA). The CGI as- anaesthesia was with isoflurane and 50% N20 in 02. All sessment was evaluated on the basis of the different scores patients recovered in the operating room immediately observed during consecutive visits. Differences between after surgery. Postoperative analgesia consisted of pro- the two groups were analyzed by the Mann-Whitney test. paraeetamol/v according to the patient request. Finally, results of the memory test, patient acceptance The efficacy of the premedicants was evaluated by as- and incidence of adverse events were compared using sessments of anxiety and sedation and by the results of the Fisher exact test. a memory test. 7-1~ Anxiety level and degree of sedation were recorded before premedication (T 0 before induction Results of anaesthesia (Tz) and on the evening after surgery (T3). The two groups were similar in terms of demographic The level of anxiety was assessed by the patient and by data, ASA status and timing of drug administration with the anaesthetist, using a 10 cm visual analogue scale respect to surgery (Table I). Before premedication, VAS (VAS) (0 cm = relaxed ..... 10 cm = very anxious). and CGI data revealed no difference in the level of anx- In addition, anxiety was evaluated by the anaesthetist iety and sedation between the two groups. using a seven point clinical global impression (CGI) scale of anxiety (0 = relaxation, 1 = apprehension, 2 = mild Assessment of anxiety anxiety, 3 = moderate anxiety, 4 = manifest anxiety, The evolution of the VAS assessments of anxiety by the 5 = severe anxiety, 6 = very severe anxiety). patient during the trial was different between the two The degree of sedation was assessed by the anaesthetist groups (P < 0.05) (Figure 1). Anxiety did not change using a 10 cm VAS (0 cm = excited, ... , 10 cm = from Tl to T2 in the hydroxyzine group while it decreased asleep) and a five-point CGI of sedation (0 = awake, in the alprazolam group (P < 0.01) during the same 1 = mild sedation, 2 = moderate sedation, 3 = pro- period. There was a decrease in the anxiety VAS assess- nounced sedation, 4 = very pronounced sedation). The ments by the anaesthetist (Figure 2) level between Tl anaesthetist was unaware of the premedicant adminis- and T2 (P < 0.001) and also between T2 and T 3 (P tered. < 0.01) in the alprazolam group. In the hydroxy- A memory test performed the evening after surgery zine group, no difference was observed between T~ consisted of four questions to which the patients had to and T 2. The anxiety decreased between T2 and T 3 (P answer yes or no = "Do you recognize the bank note < 0.01). shown at the premeditation time?," "Do you remember The evolution of the CGI assessments between T l and leaving your room?," "Do you remember the operating T2 was different between the two groups (P < 0.05). room?," "Do you remember going to sleep in the op- Hydroxyzine-treated patients became more anxious at T2. erating room?" The anxiety partially disappeared at T 3 (Figure 3). Franssen el al.: ORAL PREMEDICATION 15

TABLE 1 Demographic data of patients included in the study VERY ANXIOUS ALPRAZOI.Abl Variable Alprazolam Hydroxyzine All patients (cm) 5 h'YDROXYZn~ Age (yr) Mean 39.7 37.6 38.7 SD 11.1 10.8 40.9 Range 17-60 17--64 17--64 n 34 31 65 Weight (kg) S1~1~ S 2 Mean 71.6 70.8 71.2 SD 15.4 13.1 14.2 $3 Range 48-120 43-100 43-120 2 n 31 31 62 Before Before After premedieafioa induction sergeu Delay (time (rain) between premedication and induction) Mean 86.9 79.3 83.3 FIGURE 2 Evolution of the VAS assessments of anxiety recorded by SD 22.8 20.4 21.9 the anaesthetist before premedication, before induction of anaesthesia Range 45-140 60-120 45-140 and at the evening after surgery. Alprazolam group: S I (P < 0.001 n 32 28 60 between T I and T2), $2 (P< 0.01 between T 2 and T3). Hydroxyzine group: S 3 (P < 0.01 between T 2 and T3). Sex Male 23 (68%) 18 (58%) 41 (63%) Female 11 (32%) 13 (42%) 24 (37%)

ASA I 29 (88%) 23 (77%) 52 (83%) ltoll 1 (3%) 0 (0%) l (2%) II 3 (9%) 7 (23%) lO (15%) Missing 1 1 2

'r ANXIOUS ALPRAZOLAM (m) 5 HYDROXYZlNE ] 4 FIGURE 3 Mean anxiety scores (CGI scores) for the two treatment 3 groups recorded by the anaesthetists before premedieation, before induction and at the evening after surgery (mean + SD). 2 1' (m) 7 ~ s~ m~X.AX~D0 6 Bvforc Before zs~ premedication induction 5 y FIGURE 1 Evolution of the VAS assessments of anxiety recorded by 4 the patients before premedication and before induction of general anaesthesia. Anxiety decreased only in the alprazolam group (S) (P < 3 HYDRO~ 0.01). 2 ~O'rED Be_core Before After Assessment of sedation )remedicalion induction surgery Sedation (assessed by VAS) decreased considerably (P FIGURE 4 Evolution of the VAS assessments of sedation before < 0.001) in both groups during the course of the study premedication, before induction of anaesthesia and at the evening after but no difference between the two groups was observed surgery. Alprazolam group: S I (P< 0.001 between T 1 and T3). (Figure 4). Hydroxyzine group: S 2 (P < 0.001 between T I and T3). 16 CANADIAN JOURNAL OF ANAESTHESIA

Vital signs No differences were observed between the groups before premedication. Both systolic and diastolic BP increased in the two groups between T l and "1"2 and subsequently decreased between T2 and T 3. The changes in systolic BP were larger in the hydroxyzine than in the alprazolam group (P < 0.01). Respiratory rate and mean heart rate remained unchanged in both groups (Table II).

Discussion This study was designed to assess and compare the ef- ficacy and the safety of two oral premedicants: alpraz- olam and hydroxyzine. In agreement with the Ethical Committee, no placebo group was included in the trial to avoid unwanted effects related to stress and anxiety. 6 FIGURE 5 Mean sedation scores (CGI scores) for the two treatment groups recorded by the anaesthetists before premedieation, before Oral administration of premedicants is now largely rec- induction and on the evening after surgery (mean + SD). ommended. It is appreciated by patients, nurses and an- aesthetists because it is easy to use and comfortable, and When assessing the level of sedation by means of CGI avoids painful injection. 2,3 Given with a limited amount scores, no difference was observed at any time between of water, it does not increase the risk of gastric aspiration the two groups (Figure 5). during anaesthesia. 11,12 The comparison of the two groups revealed no dif- Memory lest ference in anxiety and sedation before premedication. The Statistical analysis of the memory test data did not reveal basal level of anxiety was low in the majority of patients any difference between the two groups. No amnesic effect at the beginning of the study. The measurement of anx- was noted with either alprazolam or hydroxyzine. iety and sedation in patients is difficult but the linear analogue scale and the CGI scale provide sensitive and Patient acceptance accurate subjective assessments of these phenomena.7 The Alprazolam and hydroxyzine were rated as satisfactory anxiety level of the patients given alprazolam decreased premedicants respectively by 25 out of 34 (73,5%) patients during the trial. This decrease was greater between T l and by 20 out of 31 (64,5%) patients but the difference and T 2 than in the post-surgery period. Simultaneously, in patient acceptance did not reach statistical significance. VAS assessment of anxiety did not reveal any change in the hydroxyzine group. On the basis of CGI scale, Adverse effects anxiety of hydroxyzine treated patients was greater at "1"2 According to the patients, there was no difference in ad- than at Tl. Therefore, we conclude that alprazolam premedi- verse events between the two groups. However, the in- cation provided a better anxiolytic effect than hydmxyzine. cidence of side effects reported by the anaesthetist was Sedation data are not consistent regarding the two higher (P < 0.01) in the hydroxyzine group (28%) than methods of evaluation. The VAS assessment of sedation in the alprazolam group (0%). These effects consisted of demonstrated decreased sedation in both groups during anxiety, stress, pain, drowsiness, gastro-intestinal prob- the trial. However, CGI assessment of sedation failed to lems and agitation at awakening. demonstrate any change. This discrepancy could be ex-

TABLE II Evolution of vital signs in each group during the trial Alprazolam Hydroxyzine T~ r~ r~ r~ r~ r3

Systolic BP (mmHg) 124.4 -I- 11.4 126 5: 17.8" 123.7+ 16.8" 120.7 -t- 17.8 129.2 -t- 18.5" 113.7 + 12.5" Diastolic BP (mmHg) 71.6 -I- 9.8 75.7 + 9.2* 71.8 -t- 11.5' 72.9 + 9 77.9 -t- 12.6" 68.9 + 9* HR (Beats" rain-I) 72-I- 11 74 + 12 75-t- 12 71 + 8 74 -t- 12 72 + 10 RR (ppm) 16 -I- 3 15 + 2 15 -t- 3 17+3 17+3 17+2

*P < 0.001. The changes in systofie BP were more pronounced in the hydroxyzine group (P < 0.01). Franssen et aL: ORAL PREMEDICATION 17 plained by the very low degree of sedation of the patients 6 Wallace G, Mindlin LJ. A controlled double-blind com- in each group. The majority of sedated patients were in parison of intramuscular lorazepam and hydroxyzine as a light sleeping state from which they were easily aroused. surgical premedicants. Anesth Analg 1984; 63: 571--6. The study failed to demonstrate any amnesic effect of 7 Maxwell C. Sensitivityand accuracy of visual analogue the two drugs. The recall of presurgical events was pre- scale: a psycho-physicalclassroom experiment. Br J Clin served in the majority of patients. This is surprising for Pharmacol 1978; 6: 15-24. alprazolam premedication because benzodiazepines pro- 8 Bond A, Laden M. The use of analogue scales in rating duce lack of recall of presurgical events more consistently subjected feelings. Br J Med Psychol 1974; 47:211-8. than other drugs such as hydroxyzine.6 However, pre- 9 Van W~ihe M, De Voogt-FrenkelE, Stijnen T. Midazolam vious studies have identified alprazolam as a potent anti- versus fentanyl, droperidol and placebo as intramuscular anxiety agent with a lower incidence of benzodiazepine premedicant. Acta Anaesthesiol Seand 1985; 29: 409-14. pharmacology related side effects such as drowsiness and 10 Raybould D, Bradshaw EG. Premeditation for day case amnesia. 4,5 surgery. Anaesthesia 1987; 42: 591-5. Safety evaluation of the premedicants was based upon 11 Splinter WM, Stewart JA, Muir JG. The effect of preop- the global assessment of tolerance by the patient, the fre- erative apple juice on gastric contents, thirst and hunger in quency of reported adverse events and the evolution of children. Can J Anaesth 1989; 36, 1: 55-8. vital signs during the trial. Both alprazolam and hydroxy- 12 McGrady EM, McDonald AG. Effectof the preoperative zine were rated by the patients as satisfactory premed- administration of water on gastric volume and pH. Br J icants. The anaesthetist reported minor side effects only Anaesth 1988; 60: 803-5. in the hydroxyzine group (28% of patients). In the ab- sence of a control group, it is impossible to state if these effects were specifically related to hydroxyzine or rather resulted from its lower anxiolytic effect. Indeed, patients given alprazolam were more relaxed when entering the operating room and experienced no side effects. Finally, regarding vital signs, statistical analysis re- vealed a difference between the two groups only in the systolic BP which was higher at T 2 in the hydroxyzine group. Once again, this finding was probably related to the higher level of anxiety of patients at that time. In conclusion, alprazolam and hydroxyzine are both efficient and safe pre-anaesthetic medications. However, a more pronounced, although modest, anxiolysis and the absence of side effects favours the use of alprazolam over hydroxyzine.

References I White PE Pharmacologic and clinicalaspects of preoper- ative medication. Ancsth Analg 1986; 65: 963-74. 2 Kanto J. Benzodiazcpincs as oral prcmedicants. Br J Anaesth 1981; 53:1179-88. 3 Hofstad B, Haavik PE, Wickstrom E, Steen PA. Benzodiazepines as oral premeditation. A comparison be- tween oxazepam, flunitrazepam and placebo. Aeta Anaes- thesioi Stand 1987; 31: 295-9. 4 Dawson G W, Jue SG, Brogden RN. Alprazolam: a review of its pharmacodynamic properties and efficacyin the treatment of anxiety and depression. Drugs 1984; 27: 132-47. 5 Fawcett JA, Howard MK. Alprazolam: pharmacokinetics, clinical efficacy,and mechanism of action. Pharmacother- apy 1982; 2: 243-54.