What is the appropriate management for a patient with shortness of breath (SOB) and missed dialysis, presenting with generalized itching, currently being treated with Benadryl (diphenhydramine)?

From the Guidelines

I recommend administering a one-time dose of IV Benadryl 25-50 mg for this dialysis patient experiencing generalized itching, as it is likely related to uremia due to missed dialysis, and Benadryl can provide relief from itching by blocking histamine receptors 1. Before administration, confirm the patient's vital signs are stable and check for any contraindications such as narrow-angle glaucoma or recent use of MAO inhibitors. The itching is likely related to uremia due to missed dialysis, as accumulated waste products can trigger histamine release and pruritus. Monitor the patient for common side effects including drowsiness, dry mouth, and potential hypotension. Also, ensure the patient receives their next dialysis session as soon as possible, as this will address the underlying cause of uremic pruritus. Consider documenting the missed dialysis and arranging prompt rescheduling to prevent further complications. Some studies suggest that oral gabapentin may also be effective in treating uraemic pruritus, but IV Benadryl is a more immediate solution for relief 1. It is essential to note that while IV Benadryl can provide temporary relief, it is crucial to address the underlying cause of uremic pruritus, which is the missed dialysis, to prevent further complications. Key points to consider:

• Confirm patient's vital signs are stable before administering IV Benadryl
• Check for contraindications such as narrow-angle glaucoma or recent use of MAO inhibitors
• Monitor for common side effects including drowsiness, dry mouth, and potential hypotension
• Ensure the patient receives their next dialysis session as soon as possible
• Consider documenting the missed dialysis and arranging prompt rescheduling to prevent further complications.

From the FDA Drug Label

INDICATIONS AND USAGE: Diphenhydramine hydrochloride in the injectable form is effective in adults and pediatric patients, other than premature infants and neonates, for the following conditions when diphenhydramine hydrochloride in the oral form is impractical Antihistaminic For amelioration of allergic reactions to blood or plasma, in anaphylaxis as an adjunct to epinephrine and other standard measures after the acute symptoms have been controlled, and for other uncomplicated allergic conditions of the immediate type when oral therapy is impossible or contraindicated.

The patient is requesting IV Benadryl (diphenhydramine) for generalized itching. The drug label indicates that diphenhydramine can be used for antihistaminic purposes, including uncomplicated allergic conditions. However, it does not specifically mention itching as an indication.

• The patient's condition (generalized itching) is not explicitly listed as an indication for IV diphenhydramine in the provided drug labels 2 2. Therefore, the use of IV Benadryl for this patient's condition is not directly supported by the FDA drug label.

From the Research

Patient Symptoms and Request

• The patient, SAMS AUDRENIA JEVETTE, is experiencing shortness of breath (SOB) and has missed dialysis.
• The patient is also experiencing generalized itching and has requested a one-time IV Benadryl administration.

Relevant Studies

• A study from 2008 3 discusses the role of bicarbonate in dialysis fluid and its potential impact on shortness of breath during dialysis.
• A 2021 study 4 reviews the use of diphenhydramine in patients with end-stage kidney disease, highlighting the lack of safety profile and dosing information for this population.
• Another study from 2013 5 notes that diphenhydramine can have adverse effects, including acute kidney injury, and urges caution when prescribing this medication.
• A 2017 study 6 describes hypersensitivity reactions in patients receiving hemodialysis, including those caused by pharmacologic agents such as iron, erythropoietin, and heparin.

Considerations for Benadryl Administration

• The use of diphenhydramine (Benadryl) in patients with end-stage kidney disease is not well-studied, and its safety profile is lacking 4.
• Diphenhydramine is highly bound to protein, which may limit its ability to dialyze and predispose patients to side effects 4.
• Caution is advised when prescribing diphenhydramine, especially in elderly patients or those with kidney disease 5.