By Derek K. Chu, Paul Oykhman and Gordon L. Sussman
CMAJ April 06, 2021 193 (14) E478-E479; DOI: https://doi.org/10.1503/cmaj.201959
Antihistamines Are Among The Most Commonly And Incorrectly Used Medicines Worldwide
Antihistamine use is most strongly supported for treating allergic rhinoconjunctivitis (“hay fever”) and urticaria (hives).1–3 Avoid off-label usage for conditions where antihistamines have questionable utility, such as in managing asthma, eczema, cough or insomnia.
First-Generation Antihistamines Are Associated With Substantial And Sometimes Fatal Adverse Effects
First-generation antihistamines (e.g., diphenhydramine [Benadryl], chlorpheniramine [Chlor-Tripolon], hydroxyzine [Atarax]) cause sedation, injury and impairment in sleep, and psychomotor and cognitive function, including impairing performance at school.1–3 Overdose can result in death from anticholinergic and anti-α-adrenergic effects, and QT prolongation (including torsades de pointes). First-generation antihistamines are on the Beers list of potentially inappropriate medications for older persons.3
Newer Antihistamines Are Safer, As Affordable And As Efficacious As First-Generation Antihistamines
Compared with first-generation antihistamines, systematic reviews of randomized controlled trials have found newer antihistamines to be safer (e.g., 4% sedation v. 28%),2–4 longer lasting (12–24 h v. 4–6 h dosing) and faster acting (50 v. 80 min).1 The World Health Organization replaced chlorpheniramine with loratadine on its essential medicines list in 2013 for these reasons (see Table 1 and Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.201959/tab-related-content for preferred antihistamines).3 Bilastine and fexofenadine are the least sedating options. However, no antihistamine should be consumed with alcohol.
Summary of preferred antihistamines for allergy and urticaria
|Antihistamine (standard single|
adult dose, mg)
|Available in liquid form?||Prescription required?||Approval for children?||Evidence for|
|HC (age)||FDA* (age)|
|Bilastine (20)||No||Yes||N/A||N/A||Lack of data|
|Cetirizine (10)†||Yes||No||Yes (2yr)||Yes (6mo)||Yes|
|Desloratadine (5)†||Yes||No||Yes (2yr)||Yes (6mo)||Yes|
|Loratadine (10)†||Yes||No||Yes (2yr)||Yes (1yr)||Yes|
|Rupatadine (10)||Yes||Yes||Yes (2yr)||N/A||Lack of data|
- Note: FDA = Food and Drug Administration, HC = Health Canada, N/A = not applicable.
- * FDA and/or supporting randomized controlled trial evidence for efficacy and safety.
- † Most affordable
- ‡ Prescription not required, but can be prescribed and covered by some provincial plans as an affordable route of accessing this medication. However, prescriptions often have barriers to access (e.g., Exceptional Access Program forms with very low approval rates).
Antihistamines Should Not Be Used Instead Of Epinephrine To Treat Anaphylaxis
Oral antihistamines can be used in addition to, but should not replace, epinephrine for the treatment of anaphylaxis.1,3 Intravenous diphenhydramine can cause vasodilation and sedation, which can worsen hypotension and confound assessment of patients with anaphylaxis.1,3
Most Antihistamines Are Safe During Pregnancy And Breastfeeding
Systematic reviews of observational studies show no association with adverse fetal or maternal outcomes with antihistamine use during pregnancy or breastfeeding, and they are also safe for children.2,3,5 There is inadequate evidence regarding the newest antihistamines (rupatadine, bilastine) to support their use in pregnancy.
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- Competing interests: Derek Chu is a CAAIF-CSACI-AllerGen Emerging Clinician-Scientist Research Fellow, supported by the Canadian Allergy, Asthma and Immunology Foundation, the Canadian Society of Allergy and Clinical Immunology and AllerGen NCE Inc. (the Allergy, Genes and Environment Network). Gordon Sussman reports grants and personal fees from Novartis, Aralez, CSL Behring, Sanofi, Pediapharm, GSK, Genentech, DBV technologies, Aimmune, AstraZeneca, Stallergenes, Merck, Pfizer, Dyax, Biocryst, Greencross, Kendrion, Shire, Leopharma, Regeneron and mdBriefCase and grants from Novartis, GSK, Genentech, DBV technologies, Aimmune, CSL Behring, AstraZeneca, Stallergenes, Merck, Pfizer, Dyax, Biocryst, Greencross, Kendrion, Leo Pharma, Regeneron, Sanofi, Blueprint, ALK, Amgen and Cliantha outside the submitted work. No other competing interests were declared.
- This article has been peer reviewed.
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- Fein MN, Fischer DA, O’Keefe AW, et al. CSACI position statement: newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the firstline antihistamines for the treatment of allergic rhinitis and urticaria. Allergy Asthma Clin Immunol 2019;15:61.
- Carson S, Lee N, Thakurta S. Drug class review: newer antihistamines: final report update 2. Portland (OR): Oregon Health & Science University; 2010.
- Chahal H [for WHO Secretariat]. Section 3: Antiallergics and medicines used in anaphylaxis: histamine-1 receptor antagonists — a critical evaluation to update Section 3. Geneva: The World Health Organization; 2012.
- Huang CZ, Jiang ZH, Wang J, et al. Antihistamine effects and safety of fexofenadine: a systematic review and meta-analysis of randomized controlled trials. BMC Pharmacol Toxicol 2019;20:72.
- Gilboa SM, Ailes EC, Pai RP, et al. Antihistamines and birth defects: a systematic review of the literature. Expert Opin Drug Saf 2014;13:1667–98.