Antihistamine Safety in Older Adult Dermatologic Patients

TAKE-HOME MESSAGE

• First- and second-generation antihistamines (H1 blockers) have unique impact on adults older than 65 years. A greater proportion of adipose body mass causes lipophilic first-generation antihistamine half-lives to be extended in this age group. Most first-generation H1 blockers inhibit CYP2D6, which decreases the metabolism of beta-blockers, antidepressants, and tramadol. Comorbidities such as glaucoma and benign prostatic hyperplasia may be worsened by antihistamines. H1 blockers contribute to anticholinergic burden, which has been associated with new dementia diagnoses. Although the balance of risks and benefits is somewhat mediated by second-generation antihistamines, even this class causes sedation at high doses. Fexofenadine is preferred to cetirizine in this population because of less impact on psychomotor function.

• In adults older than 65 years, the empiric use of antihistamines or their use for itch not driven by histamine should be avoided. Longer half-lives, the impact on metabolism of medications the patient is concurrently taking, and higher rates of anticholinergic side effects are hazards of this drug class in aging individuals.

– Margaret Hammond, MD

Written by

 

 

Anne Lynn S. Chang MD

In the review article, "Antihistamine safety in older adult dermatologic patients," the authors Grinnell et al summarize the current data and highlight gaps in scientific knowledge on this important subject. The geriatric population can be a vulnerable population due to higher prevalence of comorbid medical conditions and polypharmacy. This article discusses the importance of evaluating the geriatric dermatologic patient for root causes of pruritus rather than treating the symptoms alone, as the safety vs benefits of antihistamines for pruritus has not been extensively studied in controlled trials in this population. Use of treatments that may have a more favorable benefit-risk profile are also mentioned. This review provides useful summary tables of important drug interactions with antihistamines, adverse effects of antihistamines, and a set of questions to ask geriatric dermatologic patients when considering the use of antihistamines. These types of issues and how to manage them with geriatric dermatologic patients and their caregivers should become standard curriculum in postgraduate dermatologic training programs. Finally, there is a great medical need for increased inclusion of older adults into clinical trials to better understand the risks and benefits of particular antihistamines in the geriatric dermatology population, as pruritus is a common problem significantly affecting quality of life.

Abstract

Twenty percent of Americans will be over age 65 by 2030,1 and without a dedicated geriatrics curriculum in many residency trainings programs, dermatologists may be less familiar with age-associated side effects of common dermatologic medications. Herein, we provide a practical guide and clinical safety pearls for the use of antihistamines in older adults. This review aims to address the risks of antihistamines, anticholinergic burden and polypharmacy, pertinent pre-existing medical conditions, as well as safe alternatives for aging adult patients.

Journal of the American Academy of Dermatology

Antihistamine Safety in Older Adult Dermatologic Patients

J Am Acad Dermatol 2021 Jan 16;[EPub Ahead of Print], M Grinnell, KN Price, A Shah, D Butler 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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