Can famotidine cause confusion, especially in elderly patients or those with a history of neurological conditions?

Can Famotidine Cause Confusion?

Yes, famotidine can cause confusion and other central nervous system adverse reactions, particularly in elderly patients and those with renal impairment. 1

FDA-Recognized Risk

The FDA drug label explicitly warns that famotidine causes CNS adverse reactions including confusion, delirium, hallucinations, disorientation, agitation, seizures, and lethargy, especially in elderly patients and those with moderate to severe renal impairment. 1 This is not a theoretical risk—it is an established adverse effect requiring dosage adjustments in vulnerable populations. 1

High-Risk Populations

Elderly patients are particularly susceptible to famotidine-induced mental status changes, even at standard doses. 2, 3 The risk is amplified by:

• Renal impairment (even mild): Famotidine is substantially excreted by the kidney, and reduced clearance leads to drug accumulation and higher blood levels. 1, 3
• Advanced age alone: Elderly patients may have increased blood-brain barrier permeability, making them vulnerable even without significant renal dysfunction. 3
• Polypharmacy with anticholinergic drugs: The cumulative anticholinergic burden from multiple medications (including H2-blockers, which have anticholinergic properties) increases delirium risk. 4, 5

Clinical Presentation

Famotidine-induced confusion manifests as:

• Acute delirium with disorientation and agitation 1, 6
• Visual hallucinations and nightmares 2
• Mental status changes that develop within days of starting therapy 2, 6
• Complete resolution within 24-48 hours after discontinuation 2, 6

Dosing Adjustments to Minimize Risk

For elderly patients, use the lowest effective dose and monitor renal function closely. 1

• No renal impairment (CrCl ≥60 mL/min): Standard dosing acceptable but monitor for CNS effects 1
• Moderate renal impairment (CrCl 30-59 mL/min): Reduce dose by 50% or extend dosing interval 1
• Severe renal impairment (CrCl <30 mL/min): Reduce dose to 20 mg daily or every 48 hours 1

Safer Alternatives

When acid suppression is needed in elderly or cognitively vulnerable patients, consider proton pump inhibitors (PPIs) like lansoprazole as first-line therapy instead of H2-blockers. 2 The case literature demonstrates successful symptom resolution when switching from famotidine to lansoprazole. 2

If H2-blockers must be used for specific indications, famotidine carries similar CNS risk to other agents in this class (cimetidine, ranitidine). 5, 3 However, H1R and H2R blocking agents with anticholinergic effects are associated with cognitive decline that worsens in elderly populations. 4

Critical Management Steps

1. Maintain high clinical suspicion: Any new confusion in an elderly patient taking famotidine should prompt immediate consideration of drug-induced delirium. 5, 7

2. Discontinue famotidine immediately if confusion develops—symptoms typically resolve within 48 hours. 2, 6

3. Avoid rechallenge: Patients who develop confusion with famotidine will experience recurrence upon reexposure. 2

4. Review total anticholinergic burden: Assess all medications for cumulative anticholinergic effects, as the total burden determines delirium risk more than any single agent. 5

Common Pitfalls to Avoid

• Do not assume confusion is due to underlying dementia or infection without first considering medication toxicity—drugs cause delirium in 11-30% of elderly hospitalized patients. 5
• Do not continue famotidine at reduced doses in patients who have already developed confusion; switch to an alternative class entirely. 2
• Do not overlook mild renal impairment as a risk factor; even CrCl of 40-50 mL/min increases famotidine levels significantly. 1, 3
• Avoid combining famotidine with other CNS depressants or anticholinergic medications in elderly patients, as this compounds cognitive risk. 4