What are the concerns with using betahistine (antihistamine) in older adults?

Concerns with Betahistine Use in Older Adults

Betahistine should be used with caution in older adults due to potential side effects, with second-generation antihistamines generally being preferred when antihistamine therapy is needed in this population. 1

Safety Profile of Betahistine

Betahistine is primarily used for Ménière's disease and vestibular vertigo. While serious medical side effects are rare, there are several considerations specific to older adults:

Common Side Effects

• Headache
• Balance disorder
• Nausea
• Nasopharyngitis
• Feeling hot
• Eye irritation
• Palpitations
• Upper gastrointestinal symptoms 1

Specific Precautions

• Should be used with caution in patients with asthma
• Should be used with caution in those with history of peptic ulcer disease
• Should be avoided in patients with pheochromocytoma 1

Special Considerations for Older Adults

Older adults are particularly vulnerable to medication side effects due to:

1. Increased sensitivity to psychomotor impairment - Older adults experience greater cognitive and motor effects from medications with CNS activity 1

2. Fall risk - Increased risk for complications such as fractures and subdural hematomas caused by falls 1

3. Anticholinergic effects - While betahistine itself is not strongly anticholinergic, older adults are more susceptible to anticholinergic effects from medications in general 1

4. Polypharmacy concerns - Older adults often take multiple medications, increasing the risk of drug interactions 1

Comparison with Other Antihistamines

When antihistamine therapy is needed in older adults:

• Second-generation antihistamines are generally preferred over first-generation antihistamines due to less sedation and fewer anticholinergic effects 1

• First-generation antihistamines (like diphenhydramine) should be approached with extreme caution in older adults due to:

  • Sedative effects
  • Performance impairment
  • Anticholinergic burden
  • Risk of falls
  • Potential cognitive impairment 1

Monitoring Recommendations

If betahistine is prescribed to older adults:

• Start with lower doses and titrate slowly
• Monitor for balance issues and falls
• Reassess regularly for improvement or stabilization of symptoms
• Watch for medication intolerance or side effects 1
• Consider discontinuation if no improvement is seen after an adequate trial period

Alternative Approaches

For vestibular vertigo in older adults, consider:

• Non-pharmacological approaches first (vestibular rehabilitation exercises)
• Second-generation antihistamines if antihistamine therapy is needed
• For Ménière's disease specifically, intranasal steroids may be considered as an alternative in patients not responsive to other treatments 1

Conclusion

While betahistine has a relatively good safety profile compared to first-generation antihistamines, caution is still warranted in older adults. The decision to use betahistine should carefully weigh the potential benefits against the risks of side effects, particularly in patients with multiple comorbidities or those taking other medications.