What is the best alternative to Benadryl (diphenhydramine) for geriatric patients?

From the Guidelines

Second-generation antihistamines like cetirizine (Zyrtec), loratadine (Claritin), or fexofenadine (Allegra) are the best alternatives to Benadryl for geriatric patients. These medications are preferred because they don't cross the blood-brain barrier as readily as Benadryl, resulting in fewer cognitive side effects such as confusion, sedation, and delirium—issues particularly problematic in older adults 1. The American Geriatrics Society specifically recommends against using first-generation antihistamines like diphenhydramine in older adults through their Beers Criteria, as noted in a recent clinician's guide to geriatric assessment 1.

For allergic symptoms, cetirizine 10mg daily, loratadine 10mg daily, or fexofenadine 180mg daily are appropriate starting doses, though some elderly patients may need reduced doses based on kidney function. Key considerations include:

• Evaluating drug interactions due to polypharmacy, which is common in geriatric patients 1
• Assessing the patient's overall health and potential for adverse effects before starting any new medication
• Considering the use of melatonin (1-2mg) or discussing prescription options with a healthcare provider if sleep is the concern, as these alternatives are safer than using Benadryl as a sleep aid
• Recognizing that second-generation antihistamines have fewer anticholinergic effects, reducing risks of urinary retention, dry mouth, constipation, and blurred vision that can be especially troublesome for older patients 1.

Given the potential risks associated with first-generation antihistamines, such as increased risk of falls, fractures, and subdural hematomas, as well as anticholinergic effects like dryness of mouth and eyes, constipation, and inhibition of micturition 1, it is crucial to prioritize the use of second-generation antihistamines in geriatric patients.

From the FDA Drug Label

Clinical studies of fexofenadine hydrochloride tablets and capsules did not include sufficient numbers of subjects aged 65 years and over to determine whether this population responds differently from younger subjects. Other reported clinical experience has not identified differences in responses between the geriatric and younger subjects This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

The best alternative to Benadryl for geriatric patients is not directly stated in the provided drug label. However, fexofenadine may be considered as an option, with caution due to the potential risk of toxic reactions in patients with impaired renal function, which is more common in the elderly.

• Dose selection should be done carefully, and
• renal function monitoring may be useful. 2

From the Research

Alternatives to Benadryl for Geriatric Patients

• Second-generation antihistamines, such as loratadine, astemizole, and terfenadine, are likely to be safer alternatives to Benadryl (diphenhydramine) for geriatric patients, as they cause minimal sedation and little impairment in cognitive and psychomotor activity 3.
• Ebastine is another second-generation antihistamine that appears to be safe and effective for the treatment of allergic disorders, with no relevant effects on psychomotor performance 4.
• Loratadine has been shown to have no significant effects on cognition, psychomotor performance, mood, and sedation, making it a suitable alternative to Benadryl for geriatric patients 5.
• Other options, such as cetirizine, desloratadine, and fexofenadine, may also be considered, as they have been shown to have similar efficacy to Benadryl with less sedation 6.
• However, it is essential to note that some second-generation antihistamines, such as astemizole and terfenadine, can cause serious cardiovascular adverse effects when taken in high doses or coadministered with certain medications 3.
• The choice of alternative antihistamine should be based on the individual patient's medical history, current medications, and specific needs, and should be made in consultation with a healthcare professional.

Key Considerations

• Geriatric patients may be more susceptible to the sedating and anticholinergic effects of first-generation antihistamines, such as Benadryl 3.
• Second-generation antihistamines may be associated with a lower risk of cognitive and psychomotor impairment, but may still have potential interactions with other medications 3, 4.
• The effects of antihistamines on mood, sleep quality, and daytime sleepiness should also be considered, as some antihistamines may have negative influences on mood states 7.