What is the appropriate management for a patient in sickle cell crisis requesting intravenous (IV) Benadryl (diphenhydramine) with IV morphine, while refusing oral (PO) Benadryl (diphenhydramine)?

From the Guidelines

I would strongly advise against administering IV Benadryl in this scenario, and instead recommend oral (PO) Benadryl, as the patient's request for IV Benadryl may be driven by its sedative effects rather than therapeutic benefits, and IV morphine should be prioritized for pain control in this sickle cell crisis. The management of sickle cell crisis primarily involves adequate pain control, hydration, and addressing any underlying triggers, with a focus on opioid analgesia for pain management [ 1 ].

For pain management, IV morphine at a dose of 0.1 mg/kg every 4 hours as needed is appropriate, with dose adjustments based on pain severity and response. The use of multimodal postoperative analgesia techniques, including local or regional blocks, patient-controlled analgesia, and oral analgesia, should also be considered [ 1 ].

Regarding the patient's refusal of PO Benadryl, it is essential to address their concerns and explain the risks associated with IV Benadryl, including increased sedation, hypotension, and potential for abuse when combined with opioids. If the patient has legitimate concerns about oral medication absorption during crisis, alternative routes of administration or formulations can be explored. However, the primary focus should remain on providing adequate pain control with appropriate opioid analgesia and addressing the patient's hydration and oxygen needs, rather than relying on IV antihistamines, which offer no specific benefit for the pathophysiology of sickle cell crisis [ 1 ].

Key considerations in managing this patient include:

• Prioritizing IV morphine for pain control
• Avoiding IV Benadryl due to its potential risks and lack of therapeutic benefits in sickle cell crisis
• Addressing patient concerns about oral medication absorption and exploring alternative formulations if necessary
• Focusing on hydration, oxygen therapy if needed, and treating underlying triggers of the sickle cell crisis.

From the Research

Sickle Cell Crisis Management

• The patient is requesting IV Benadryl with IV morphine for sickle cell crisis and refusing PO Benadryl.
• There is no direct evidence in the provided studies to support the use of IV Benadryl for sickle cell crisis management 2, 3, 4, 5, 6.
• However, studies suggest that opioids such as morphine are commonly used for pain management in sickle cell disease 4.
• The use of adjuvants like ketorolac, magnesium sulfate, and ibuprofen with opioids has been shown to have a favorable effect on pain reduction in sickle cell crisis 3.
• One study found that arginine and ibuprofen could produce additional analgesic effects when combined with morphine in vaso-occlusive crisis 3.
• Another study suggested that ketorolac did not have a narcotic-sparing effect in adult patients with sickle cell vaso-occlusive crisis pain 6.

Pain Management in Sickle Cell Disease

• Opioids are the major family of analgesics used for treating severe pain in sickle cell disease, but they may have organ-specific pathological effects 4.
• The aim of treatment should be to provide effective analgesia while minimizing the risks associated with opioid use 4.
• Guidelines for acute pain crisis management in sickle cell disease have been produced, but reports indicate that these guidelines are often not followed, and care is suboptimal 5.
• Innovative means of delivering initial opioids and availability of specialist units may improve patient experience and outcomes 5.