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Ref 2. WHO Histamine-1 Receptor Antagonists
Ref 2. WHO Histamine-1 Receptor Antagonists
Antihistamines, the first line treatment for conditions such as allergic rhinitis and urticaria, are
amongst the most commonly used medications in the world with more than 40 histamine-1
antagonist agents available. The 18th Expert Committee on the Selection and Use of Essential
Medicines requested an evaluation for the use of chlorphenamine (the systemic first generation
histamine-1-receptor antagonist currently on the EML) versus diphenhydramine.
This review will provide efficacy, safety and cost information on two 1st generation
antihistamines (FGAHs) – chlorphenamine and diphenhydramine. However, considering the
favorable pharmacotherapy and side-effect profile of 2nd generation systemic antihistamines
(SGAHs), this review will also provide an overview of efficacy, safety and cost of three over-the-
counter, SGAHs (cetirizine, loratadine and fexofenadine) and compare them to FGAHs.
3. If so, should this be an addition or replacement to the FGAH currently on the list?
Page 1 of 63
Table of Contents
List of Tables .................................................................................................................................. 1
Acronyms and Abbreviations: ........................................................................................................ 2
Executive Summary ........................................................................................................................ 3
I. Background and Rationale for this review .............................................................................. 6
II. Public health relevance of allergic conditions ..................................................................... 7
III. Methods.............................................................................................................................. 10
IV. Medications, Clinical Efficacy and Safety Evaluation ...................................................... 10
1. Similarities and differences amongst FGAHs and SGAHs ............................................... 10
2. Pharmacokinetic (PK) and Pharmacodynamic (PD) properties of antihistamines ............ 11
3. Comparing chlorphenamine and diphenhydramine ........................................................... 13
4. Treatment of selected common conditions with FGAH and SGAH.................................. 17
A. Allergic Rhinitis .................................................................................................................... 17
B. Urticaria ................................................................................................................................. 23
C. Anaphylaxis (adjunct)............................................................................................................ 28
5. Safety Profile of Antihistamines ........................................................................................ 29
V. Use of Antihistamines in special populations .................................................................... 36
1. Elderly ................................................................................................................................... 36
2. Children and Infants .............................................................................................................. 36
VI. Cost, Regulatory and Current NEML Availability Evaluation .......................................... 41
VII. Summary and Recommendations ...................................................................................... 43
Appendix ....................................................................................................................................... 45
Appendix 1 – Drug-Drug Interactions: 1st Generation Antihistamines .................................... 46
Appendix 2 – Drug-Drug Interactions: 2nd Generation Antihistamines.................................... 48
Appendix 3 – Precautions, Contraindications and Breast Feeding Risk of 1st Generation
Antihistamines........................................................................................................................... 49
Appendix 4 – Precautions, Contraindications and Breast Feeding Risk of 2nd Generation
Antihistamines........................................................................................................................... 50
Appendix 5: Non-allergic conditions treated with Antihistamines ........................................... 51
A. Motion Sickness, Nausea, Emesis ......................................................................................... 51
B. Antitussive uses ..................................................................................................................... 51
C. Insomnia (Night-time sleep aid) ............................................................................................ 52
D. Extrapyramidal Symptoms .................................................................................................... 53
Appendix 6: EML Application Sections ................................................................................... 54
References ..................................................................................................................................... 56
List of Tables
Table 1: Medications under review for safety, efficacy and cost ...................................................................................7
Table 2: FDA approved and off-label indications for antihistamines and strength of evidence and recommendation.8
Table 3: PK and PD properties of antihistamines .........................................................................................................12
Table 4: Efficacy and side-effects of FGAHs in Allergic Rhinitis and Urticaria .............................................................15
Table 5: Guidelines on Treatment of Allergic Rhinitis ..................................................................................................18
Table 6: Efficacy and safety of SGAH in Allergic Rhinitis ..............................................................................................19
Table 7: Guidelines and Systematic Reviews on Treatment of Urticaria .....................................................................24
Table 8: Efficacy and Safety of SGAHs in Urticaria ......................................................................................................25
Table 9: Comparative side-effect profile of first and second generation antihistamines ............................................31
Table 10: Side-effects: Sedation, drowsiness, psychomotor impairment ....................................................................32
Table 11: Safety in children and breast feeding...........................................................................................................38
Table 12: Cost comparison of 1st and 2nd generation antihistamines........................................................................42
Table 13: Availability of reviewed medications on NEMLs of 15 nations ....................................................................42
Table 14: Treatment Details for Loratadine.................................................................................................................44
Table 15: Dose Adjustments for Loratadine.................................................................................................................44
Acronyms and Abbreviations:
EC – Expert Committee
inj - Injection
IV – Intravenous
PD – Pharmacodynamics
PK – Pharmacokinetic
PO – Oral
tab – Tablet
US – United States
Page 2 of 63
Executive Summary
This application has reviewed the efficacy and safety of first generation antihistamines (FGAHs)
- chlorphenamine and diphenhydramine for section 3 of EML and EMLc as requested by the 18th
Expert Committee. The application also reviewed the efficacy and safety of three second
generation antihistamines (SGAHs) - loratadine, cetirizine and fexofenadine and compared them
to FGAHs. Evidence for treatment of two common allergic conditions – allergic rhinitis and
urticaria – with these five antihistamines is provided. The application also provides a discussion
on the use of antihistamines in anaphylaxis. The use of these medications in the elderly and
children is also discussed. Finally, the application analyzed the cost of the five medications as
well as their availability of National EMLs of 15 Low and middle income countries (LMICs).
Overall, there is a lack of high quality data to effectively compare and contrast the two FGAHs.
The review found no RCTs that satisfactorily compared efficacy and safety of chlorphenamine
and diphenhydramine for use in allergic rhinitis, urticaria and anaphylaxis. The evidence from
five RCTs does show similar effectiveness and side effect profile of the two medications for both
allergic rhinitis and urticaria. However, the review has shown significant evidence comparing
efficacy and safety of SGAHs with FGAHs. Fifteen RCTs show similar efficacy between the two
classes of medications in treating allergic rhinitis with significantly less side effects (in
frequency and severity) resulting from use of SGAHs. For treatment of urticaria, nine RCTs
showed similar efficacy between FGAHs and SGAHs, with lower incidence of side effects. Six
RCTs, three retrospective studies and one systematic review provide evidence establishing
superior safety profile of SGAHs over that of FGAHs. Significant sedation and psychomotor
impairment is observed with FGAHs compared to SGAHs.
The review provides a detailed discussion on the use of antihistamines in anaphylaxis and
concludes that there is no strong evidence recommending the use of antihistamines for this
indication. There are no RCTs available that evaluate the use of antihistamines in anaphylaxis.
The referenced guidelines strongly recommend the use of epinephrine as first line treatment for
anaphylaxis and only recommend antihistamines as adjunct therapy for possible benefit in
histamine mediated cutaneous reactions.
Due to the anticholinergic side effects, the use of FGAHs in the elderly is strongly discouraged
and SGAHs are recommended for use in allergic conditions. Evidence from 5 RCTs, two
pharmacokinetic studies, a systematic review and guidelines conclude against the use of FGAHs
in infants and children due to risk of sedation and death and establish safety of SGAHs.
For cost and availability, using MSH pricing guide, the monthly treatment cost with loratadine is
more economical than chlorphenamine and 53% of the surveyed LMICs already have a SGAHs
on their respective National EMLs.
Based on the evidence available, this review makes the following recommendations: 1) Retain
chlorphenamine on the EML for adults, and but the age restriction be 6 years ( currently it is 1
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year). 2) Delete chlorphenamine from the EMLc. 3) Add loratadine tablet (10mg) and syrup
(1mg/1mL) to the EML and EMLc, with a square box designation. 4) An age restriction of 2
years and older for loratadine is recommended.
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Review
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I. Background and Rationale for this review
The WHO 18th Expert Committee on the Selection and Use of Essential Medicines (18th EC)
requested a comparative review for chlorphenamine (systemic antihistamine currently on the
EML) versus diphenhydramine, to update Section 3 of the EML titled “Antiallergics and
Medicines Used in Anaphylaxis.”[1]
Allergic conditions such as allergic rhinitis and urticaria are histamine mediated reactions that
may require management with pharmacological agents.[2-4] Histamine is a naturally occurring
compound produced and present all throughout the human body. Likewise, histamine receptors,
H-1, H-2, H-3, and H-4 are expressed throughout the body and in-conjunction with histamine,
play important roles in regulation of functions ranging from embryo development to wound
healing and regeneration. The primary target of the antihistamines under review is the histamine-
1 (H-1) receptor, which is involved in central nervous system functions such as sleep and waking
cycles (circadian rhythm), energy regulation, cognition, memory and in peripheral body
functions such as allergic inflammation and reactions causing H-1 mediated hypotension,
tachycardia, flushing and headache via its effects on the cardiovascular system.[3-7]
This review will compare efficacy, safety and cost of two 1st generation antihistamines (FGAHs)
chlorphenamine and diphenhydramine for use as anti-allergics and in anaphylaxis. Considering
the favorable, pharmacotherapy and side-effect profile of the 2nd generation systemic
antihistamines (SGAHs), this review will also provide an overview of efficacy, safety and cost of
three SGAH (cetirizine, loratadine and fexofenadine) and compare them to FGAHs for use as
anti-allergics and in anaphylaxis.[3, 5, 7, 23-28]
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The two FGAH are reviewed
Table 1: Medications under review for safety, efficacy and cost
because they are requested by
the EC and the three SGAH Agent(s) or Class Comparative
were selected for review due to Medication or Class
Comparison
their classification as over-the- 1 Chlorphenamine vs. Diphenhydramine
counter (OTC) medications by 2 FGAH: SGAH: cetirizine,
the FDA and their off-patent chlorphenamine and vs. loratadine and
status.[9] OTC medications are diphenhydramine fexofenadine
defined as medications that are
safe and effective for use by the general public without seeking treatment by a health
professional.[9] Given that anti-histamines are amongst the most commonly used medications in
the world, their OTC status is an important consideration especially in situations where access to
qualified prescribers may be limited. Table 1 summarizes the medications under review.
Appendix 6 on page 54 contains a list of EML application questions with section by section
references to this review.
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Table 2: FDA approved and off-label indications for antihistamines and strength of evidence and recommendation
Medication FDA Approved Indication and Strength of Recommendation and Off-Label (Non-FDA approved) Indication and Strength of
Evidence (R/E) Recommendation and Evidence (R/E)
Diphenhydramine Indication Adults (R/E) Children (R/E) Indication Adults (R/E) Children (R/E)
Allergic rhinitis Yes (Class IIb / Yes (Class IIb / Category Chemotherapy-induced No (Class IIb / No evidence
Category B) B) nausea and vomiting Category B)
Anaphylaxis; Yes (Class IIb / Yes (Class IIb / Category Extrapyramidal disease - No (Class IIb / No evidence
Adjunct Category B) B) Medication-induced Category B)
movement disorder
Common cold Yes (Class IIb / Yes (>6yr of age) (Class Hyperemesis gravidarum No (Class IIb / No evidence
Category B) IIb / Category B) Category B)
Insomnia Yes (Class IIb / Yes (>12yr of age) Local anesthesia No (Class IIb / No evidence
Category B) (Class IIb / Category B) Category B)
Motion sickness Yes (Class IIb / Yes (Class IIb / Category
Category B) B)
Parkinsonism Yes (Class IIb / Not FDA approved
Category B)
Pruritus of skin Yes (Class IIa / Yes topical formulation
Category B) only, 2 y and older
(Class IIa / Category B)
Chlorphenamine Allergic rhinitis Yes (Class IIa / Yes (>6yr of age) (Class Contrast media adverse No (Class IIb / No (Class IIb /
Category B) IIa / Category B) reaction Category B) Category B)
Common cold Yes (Class IIb / Yes (>6yr of age) (Class Systemic mast cell disease No (Class IIb / No (Class IIb /
Category B) IIb / Category B) Category B) Category B)
Loratadine Idiopathic urticaria, Yes (Class IIb / Category Yes (>2yr of age) (Class Asthma No (Class IIb / No (Class IIb /
chronic B) IIb / Category B) Category B) Category B)
Allergic rhinitis Yes (Class IIa / Category Yes (>2yr of age) (Class Eosinophilic non-allergic No evidence No evidence
B) IIa / Category B) rhinitis
Cetirizine Allergic rhinitis Yes (Class IIa / Category Yes (>6months of age) Asthma, adjunct No (Class IIa / No evidence
(Perennial) B) (Class IIa / Category B) Category B)
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Allergic rhinitis Yes (Class IIa / Category Yes (>2yr of age) (Class Atopic dermatitis No (Class IIb / No (Class IIb /
(Seasonal) B) IIa / Category B) Category B) Category B)
Urticaria, chronic Yes (Class IIa / Category Yes (>6months) (Class Urticaria, acute No (Class IIb / No evidence
B) IIa / Category B) Category B)
Fexofenadine Idiopathic urticaria, Yes (Class IIa / Category Yes (>6yr, oral tablets, Hymenoptera No (Class IIb / No evidence
chronic B) orally disintegrating immunotherapy, Category B)
tablets; 6 months to 11 Pretreatment
years, oral suspension
(Class IIa / Category B)
Allergic rhinitis Yes (Class IIa / Category Yes 6yr and older, oral Allergic rhinitis (Perennial) No (Class IIb / No evidence
(Seasonal) B) tablets, orally Category B)
disintegrating tablets; 2
to 11 years, oral
suspension (Class IIa /
Category B)
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III. Methods
A search was conducted using all PubMed databases and Cochrane databases for reviews,
observational studies and RCTs:
The online databases of four stringent regulatory authorities were also searched for pertinent
information: FDA (United States), TGA (Australia), MHRA (UK) and Health Canada. Other
online databases searched were: British National Formulary, and Micromedex and Lexi-Comp
(clinical pharmacy databases). All SRAs and databases were selected based on their online
availability in English.
The following search terms were used: first generation antihistamines; chlorphenamine; chlor-
trimeton; diphenhydramine; second generation antihistamines; cetirizine; loratadine;
fexofenadine; allegra; zyrtec; claritin; safety and efficacy of medications under review;
pharmacokinetic and pharmacodynamics of medications under review; allergic rhinitis; rhinitis;
urticaria; chronic urticaria; extrapyramidal symptoms; EPS; akathisia; dystonic reactions;
dystonia; pseudoparkinsonism; antipsychotic induced EPS; anaphylaxis; food allergies and
antihistamines; motion sickness and antihistamine; nausea/vomiting/emesis and antihistamine
use; antitussive; cough suppression and antihistamine use. A title review was conducted to
identify relevant results followed by an abstract review.
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to differ significantly. The SGAHs are related and in some cases are derivatives or
metabolites of their predecessors, the FGAHs.[3]
The major distinction made between these medicine classes is on the basis of their side-
effect of sedation. The FGAHs are referred to as ‘sedating’ while the SGAHs as ‘non-
sedating.’[3] This broad distinction is based on two primary differences between these
medicine classes: 1) SGAHs are far more specific to H-1 receptors compared to their
older counterparts that also exhibit an affinity for muscarinic, serotonin and alpha-
adrenergic receptors. [3, 26] And 2) FGAHs are considered lipophilic compounds that are
able to cross the blood brain barrier as opposed to the SGAHs, which lack this ability. [3,
8, 26] These differences in receptor specificity and liphophilicity cause FGAHs to display
significant central nervous system, cardiovascular system, and gastrointestinal system
side-effects discussed below.[3, 8, 26]
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Table 3: PK and PD properties of antihistamines
Page 12 of 63
3. Comparing chlorphenamine and diphenhydramine
It should be noted that the FGAHs came into existence over 6 decades and most of the
40-plus antihistamine agents available have never been optimally studied in RCTs and
some of these agents and their indications were approved for use prior to the current
standards for medication approval processes requiring RCTs to demonstrate safety and
efficacy in adults and children.[35, 36]
Efficacy and Safety: No trials comparing these two agents in terms of efficacy or safety
for allergic rhinitis, urticaria or anaphylaxis were found. However, their efficacy as anti-
histamine agents for treatment of allergic rhinitis and urticaria and their safety via side-
effect profile as a class is well established in literature.[25, 37-40] An RCT including 64
Nigerian patients with allergic rhinitis found chlorphenamine to be significantly better
than vitamin C (control) at relieving symptoms.[37] Another RCT with 15 elderly
patients, found both diphenhydramine and chlorphenamine to significantly better than
placebo in suppressing histamine-induced cutaneous allergic reactions.[25] A multicenter
RCT with 188 chronic urticaria participants found hydroxyzine (a FGAH) to be as
effective as cetirizine and more effective than placebo to control urticaria symptoms.[40]
Table 4 below summarizes several RCTs examining efficacy and side-effects of FGAHs
in treatment of allergic rhinitis and urticaria.
Mechanism of Action and PK/PD: Section IV-1 closely examined the mechanism of
action of antihistamines. Table 3 shows the pharmacokinetics and pharmacodynamics
data on diphenhydramine and chlorphenamine. There is less data available on the PK and
PD profile of chlorphenamine compared to diphenhydramine. Data are still lacking for
dosing of chlorphenamine in hepatic and renal insufficiency.
Pregnancy Category: Table 3 above also shows the pregnancy categories assigned to
these agents by the FDA and TGA. FDA categorizes all antihistamines under review as
category B, with the exception of fexofenadine, which is considered category C. TGA
considers the FGAHs as category A, cetirizine and fexofenadine as category B2 and
loratadine as category B1.
Indications: The primary differences between these two FGAHs are best defined in Table
2. Diphenhydramine has been approved by an SRA (FDA) for 7 conditions while
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chlorphenamine has been approved for 2 conditions. Chlorphenamine is approved for use
in allergic rhinitis, urticarial allergic reactions and for adjunct use in anaphylaxis in the
United Kingdom.[43] The reasons for this difference in approved indications by different
SRAs may be numerous, including but not limited to, original manufacture’s incentives
for seeking multiple indications and gaining market share, competitiveness of the market,
and availability of data. Furthermore, as Table 2 illustrates, in addition to approved
indications, there is data available on diphenhydramine for off-label use in 4 conditions,
compared to the data available for the use of chlorphenamine in 2 off-label conditions.
Cost and Availability: The comparative cost and availability of these agents on the
NEMLs is provided in Table 12 and Table 13 below, respectively.
In section III – 4 below, FGAHs, chlorphenamine and diphenhydramine are examined for
specific uses in selected common conditions and their efficacy and safety profile will be
compared with SGAHs.
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Table 4: Efficacy and side-effects of FGAHs in Allergic Rhinitis and Urticaria
Page 16 of 63
4. Treatment of selected common conditions with FGAH and SGAH
A. Allergic Rhinitis
Allergic rhinitis is a common condition affecting up to 30% of adults and 40% of
children worldwide and complicating asthma management in up to 90% asthmatics who
also suffer from allergic rhinitis.[29, 45] Allergic rhinitis has tremendous effect on a
patient’s quality of life; it can impact social life, sleep, academics and work and
contribute to substantial indirect economic impact.[32] FGAHs are widely used in adults
and children for management of allergic rhinitis.[35] Several classes of medications are
used for the treatment of allergic rhinitis including antihistamines, corticosteroids, mast
cell stabilizers, decongestants, nasal anticholinergics and leukotriene-receptor
agonists.[46] Inhaled glucocorticosteroids are considered to be the most effective
medications for the treatment of allergic rhinitis in both adults and children.[32, 47]
SGAHs are the preferred and recommended medications by multiple guidelines,
including guidelines developed in collaboration with WHO, as the first-line treatment
option for allergic rhinitis; and due to the adverse effects and safety concerns of FGAHs,
guidelines recommend that FGAHs should be avoided.[4, 32, 46, 48-51] The GRADE
recommendation for use of SGAHs in AR is strong.[46] Table 5 below summarizes
guidelines and their recommendations for the use of SGAHs while avoiding use of
FGAH for this indication, limiting their usefulness.
Table 6 below summarizes the RCT data showing efficacy of SGAHs for the treatment of
AR, including as compared to FGAHs. Although there is a lack of data to determine
substantial differences within distinct chemicals in SGAH class, but they appear to be
equally effective and safe.[2, 3] However, a 28-day prospective, randomized, double-
blind, parallel-group studied efficacy of loratadine versus cetirizine in 80 children 2 to 6
years of age, with perennial allergic rhinitis and found that while both treatments were
effective, cetirizine provided significant, greater relief for symptoms of rhinorrhea,
sneezing, nasal obstruction and nasal pruritus compared to loratadine.[52] A post hoc
analysis of a multi-center, randomized, placebo-controlled, double-blind, double-dummy
study comparing loratadine and fexofenadine in 835 seasonal allergic rhinitis patients
between 12 and 60 years old found that loratadine was significantly more effective in
providing relief over fexofenadine by day 2 of treatment period; possibly indicating faster
clinical onset of loratadine.[53]
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Table 5: Guidelines on Treatment of Allergic Rhinitis
Page 18 of 63
Table 6: Efficacy and safety of SGAH in Allergic Rhinitis
A placebo-controlled Multi-center, 124 children of Cetirizine 5mg twice Assessment of Cetirizine provided more mean symptom free days than did
trial of cetirizine in double-blind, both sexes aged daily, efficacy of placebo, 56.2% and 29.7%, respectively. This 26.5%
seasonal allergic placebo-controlled, between 6 and 12 cetirizine difference was considered clinically significant.
rhino-conjunctivitis parallel group study years with pollen- or placebo twice daily
Page 21 of 63
in children aged 6 to associated rhino- for 14 days Improvement in individual daily symptoms was greater for
12 years. Masi M, et conjunctivitis cetirizine than placebo.
al. (1993)[62]
Once-daily Randomized, 209 children, 6 to Cetirizine syrup (5 or Evaluate the Cetirizine 10 mg produced a significantly greater mean total
cetirizine effective in double-blind, 11 years of age 10 mg daily) safety and symptom severity (TSS) reduction than placebo (P < 0.05)
the treatment of placebo-controlled with seasonal efficacy of over the treatment period.
seasonal allergic trial allergic rhinitis or placebo for 4 weeks cetirizine syrup
rhinitis in children Cetirizine 5 mg once daily produced mean reductions in
aged 6 to 11 years: a weekly TSS, however, this did not differ statistically from
randomized, double- placebo.
blind, placebo-
controlled study. The most commonly reported adverse reactions to both
Pearlman DS, et al. cetirizine and placebo were headache, pharyngitis, and
(1997)[63] abdominal pain; these incidences were not statistically
between treatment and placebo.
The health related Multicenter, open- 544 children, 6 to Cetirizine syrup 10 mg Assessment of Cetirizine provided significant improvements in HRQL in all
quality of life effects label, non- 11 years of age once daily for 4 weeks health-related age groups (6-7, 8-9, 10-11 years) (p < 0.001) during the
of once-daily comparative study with seasonal quality of life treatment period.
cetirizine HCl syrup allergic rhinitis (HRQL)
in children with
seasonal allergic
rhinitis. Gillman SA,
et al. (2002)[64]
Double-blind prospective, 80 children, 2 to 6 Cetirizine 0.2mg/kg Evaluate Cetirizine produced significantly greater inhibition of the
comparison of randomized, double- years of age, with comparative wheal response compared with loratadine (P <.0001)
cetirizine and blind, longitudinal, perennial allergic Loratadine 0.2mg/kg efficacy and
loratadine in parallel-group study rhinitis safety of Cetirizine and loratadine produced comparable improvements
children ages 2 to 6 for 28 days cetirizine and in symptoms
years with perennial loratadine.
allergic rhinitis. Cetirizine was more effective than loratadine in relieving the
Sienra-Monge, J.J., symptoms of rhinorrhea, sneezing, nasal obstruction, and
et al. (1999)[52] nasal pruritus (P <. 0001)
Page 22 of 63
B. Urticaria
Urticaria is a group of diseases which result from a large variety of underlying causes and
can be induced by a diverse range of factors, and with variable clinical presentation,
generally with wheals and hives.[14, 29] The goal of the treatment for all presentations of
urticaria is the same – complete symptom relief. However, given the idiopathic nature of
most urticaria cases, the treatment generally consists of symptomatic relief with
pharmacotherapy and avoidance of inducing triggers.[13, 14, 65] Recommended first line
treatment agents are SGAH such as loratadine, cetirizine and fexofenadine, with
diphenhydramine and chlorphenamine as adjunct treatments.[4, 10, 13, 14, 65] The
evidence for efficacy and safety of SGAHs in treating urticaria or cutaneous histamine
reactions in reviews and RCTs is well established as reduction in pruritus and number of
wheals following SGAH treatment.[3, 25, 39, 40, 44, 65-73]
The quality of evidence for treating acute urticaria with SGAH is low; however, the
recommendation for the intervention is strong.[14] For the treatment of chronic urticaria
with a SGAH the level of evidence is high and the recommendation for the intervention is
strong.[2] A review using GRADE criteria found high quality of evidence with a strong
recommendation for the efficacy and safety of SGAHs in treatment of chronic
urticaria.[2] SGAHs have similar efficacy in treatment of chronic urticaria as their
predecessors, FGAHs, with reduced side-effect burden.[3, 74] A double-blind RCT
showed that fexofenadine was more effective at penetrating the skin than
diphenhydramine, therefore, likely able to provide more effective activity on H-1
receptors in the skin.[75] Another double-blind RCT compared fexofenadine, loratadine
and chlorphenamine and found higher distribution of SGAHs in the skin and their
superiority in suppression of wheals and flares compared to FGAH.[76] However, a
literature review concluded that both first and second generation antihistamines appear to
have similar efficacy in treatment of chronic urticaria.[3] And a 4-week multicenter,
randomized, double-blind, double-dummy, placebo-controlled safety and efficacy study
comparing cetirizine 10mg once daily and hydroxyzine (a FGAH) 25mg three times
daily, found the two treatments to be equally effective in reduction resolution for chronic
urticaria compared to placebo.[40] However, the study found a significant difference in
reduction of urticaria and pruritus episodes within 1 day of cetirizine treatment compared
to hydroxyzine and placebo.[40]
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Table 7: Guidelines and Systematic Reviews on Treatment of Urticaria
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Table 8: Efficacy and Safety of SGAHs in Urticaria
Page 27 of 63
C. Anaphylaxis (adjunct)
Anaphylaxis is a severe, life-threatening condition resulting from exposure to an
allergen that causes a systemic allergic reaction and has the potential to cause
death by compromising the pulmonary and cardiovascular systems.[12, 77-79]
The response to the allergen itself is intense and widespread resulting in
involvement of dermatologic, respiratory, cardiovascular, gastrointestinal, and
nervous systems. Treatment of this condition is an absolute necessity to prevent
loss of life.[12, 77-79] Antihistamines have been in use for adjunctive treatment
of anaphylaxis since before the advent of evidence based practice. FGAHs,
specifically diphenhydramine and chlorphenamine, due to their availability as
parenteral formulations, have been used widely and they continue to be listed on
guidelines as adjunctive treatment.[19, 80-83] When considering the use of
antihistamines in anaphylaxis, the World Allergy Organization states that:
Other published literature agrees with the World Allergy Association in stating
that while H-1 antagonists, both FGAHs and SGAHs, may be useful in controlling
cutaneous manifestations of anaphylaxis, there is no direct outcome data showing
the effectiveness of antihistamines in anaphylaxis.[80, 81] Furthermore,
epinephrine has far more clinical evidence to support its use over H-1
antihistamines in treatment of anaphylaxis.[16] And while H-1 antihistamines are
useful for relieving itching and urticaria, they do not relieve stridor, shortness of
breath, wheezing, GI symptoms, or shock.[16]
A Cochrane review concluded that there is no evidence from RCTs for the use of
H-1 antagonists in treatment of anaphylaxis.[82] Additionally, as discussed
previously in this document, FGAHs are notorious for causing sedation and
cognitive and psychomotor impairment, these side-effects may contribute to
decreased awareness of anaphylaxis symptoms.[16] Guidelines state that if use of
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an H-1 antagonist is indicated in this setting, an alternative dosing with a less-
sedating, oral SGAH such as cetirizine, may be recommended given its relatively
rapid onset of action.[16]
The above discussion illustrates not only the lack of evidence and support for use
of H-1 antagonist in anaphylaxis, but also shows that if it is to be used, a non-
sedating SGAH may be used as well unless a parenteral formulation is indicated.
Page 29 of 63
With specific attention to the sedation side-effect, a double-blind RCT determined effects
of diphenhydramine (FGAH), fexofenadine (SGAH) or alcohol on 40 licensed drivers
with seasonal allergic rhinitis.[100] The study found slower response time with alcohol
and diphenhydramine than with fexofenadine. Furthermore, the study established that
diphenhydramine caused greater impairment in driving than did alcohol.[100] Additional
studies have found that FGAHs, specifically chlorphenamine and diphenhydramine, are
also associated with loss of productivity in the workplace, injuries and deaths in both
aviation and traffic related accidents.[101-104] In fact, the International Civil Aviation
Organization recommends that aircraft operators requiring antihistamine medications be
treated with a non-sedating SGAH such as fexofenadine or loratadine.[35] While SGAHs
are widely regarded as non-sedating, it is possible for sedation to occur with these agents
when their maximum recommended doses are exceeded.[4, 90, 105, 106] A double-blind,
cross-over trial comparing impairment of driving performance with cetirizine 10mg,
loratadine 10mg or placebo, concluded that at these doses, cetirizine has the potential to
cause mild impairment of performance but not loratadine.[107] Table 10 below
summarizes several studies providing evidence on sedation properties of FGAHs and
comparisons to SGAHs.
Another venue for side effects results from the significant cytochrome (hepatic) P-450
isozymes mediated metabolism of FGAHs; this makes them exceedingly likely to
participate in or be responsible for clinically relevant drug-drug interactions. For
example, diphenhydramine is a cytochrome 2D6 enzyme inhibitor which can lead to
increased plasma levels of metoprolol, an anti-hypertensive.[110] Appendices 1 and 2 list
detailed drug-drug interactions (DDIs), including severity of interactions for the five
medications reviewed. The medication interaction tables include possible clinically
important interactions and the associated level of documentation. These DDI tables
illustrate the contrast difference between DDIs for FGAHs and SGAHs.
Diphenhydramine and chlorphenamine are concerning for 13 and 6 medication
interactions, respectively; while loratadine, cetirizine and fexofenadine have 2, 1 and 3
interactions, respectively.
Finally, appendices 3 and 4 detail the precautions, contraindications and breast feeding
safety information of both FGAHs and SGAHs. Both diphenhydramine and
chlorphenamine should be avoided during breastfeeding. For SGAHs, loratadine and
fexofenadine are deemed safe for breast-fed infants, while the risk to the infant has not
Page 30 of 63
been elucidated with cetirizine and should be avoided. This data further establish the
superior safety profile of SGAHs.
Given this comparison, it is apparent that SGAHs have a better safety and tolerability
profiles, and have at least similar efficacy compared with FGAHs.
Table 9: Comparative side-effect profile of first and second generation antihistamines
Cardiovascular Dose-related sinus tachycardia; reflex tachycardia and No major concern in the United
System supraventricular arrhythmias; dose related prolongation States since regulatory approval
of the QT interval and ventricular arrhythmias reported was withdrawn for astemizole and
for diphenhydramine other 1st generation agents. terfenadine.
Anti- After therapeutic doses, may cause pupillary dilatation, Rare, no major concerns for anti-
Cholinergic dry eyes, dry mouth, urinary retention and hesitancy, cholinergic side-effects.
gastrointestinal motility, constipation, erectile
dysfunction, memory deficits; peripheral vasodilatation,
postural hypotension, dizziness; contraindicated in
patients with glaucoma or prostatic hypertrophy.
Overdose Central nervous system effects — extreme drowsiness, No serious toxic effects or deaths
lethargy, confusion, delirium, and coma in adults; reported.
paradoxical excitation, irritability, hyperactivity,
insomnia, hallucinations, and seizures in infants and
young children; in adults and children, central nervous
system effects predominate over cardiac adverse effects;
death may occur within hours
after ingestion of medicine in untreated patients
Table adapted with modifications from Simons, ER [3]
Page 31 of 63
Table 10: Side-effects: Sedation, drowsiness, psychomotor impairment
Page 35 of 63
V. Use of Antihistamines in special populations
1. Elderly
Use of FGAHs in the elderly is not generally recommended due to the side effects
associated with this class of medications.[24, 25, 84, 111, 112] According to the Beers
criteria, a project aimed at using comprehensive, systematic review and grading of the
evidence on drug-related problems and adverse drug events (ADEs) to promote safe use
of medications in older adults, both chlorphenamine and diphenhydramine should be
avoided in the elderly. The warning is issued based on the highly anticholinergic effects
of these agents, combined with reduced clearance with advanced age, leading to a greater
risk of confusion, dry mouth, constipation and toxicity. However, the use of
diphenhydramine in special situations such as acute treatment of severe allergic reaction
can be considered appropriate. Level of evidence for this Beers recommendation is
moderate and the strength of recommendation is high.[112] Furthermore, these agents
should be avoided in patients with chronic constipation unless no other alternatives are
available as it can worsen constipation. Also, these agents should not be used by men
with lower urinary tract symptoms or benign prostatic hyperplasia as it may decrease
urinary flow and cause urinary retention. The strength of recommendation for this is
weak while the quality of evidence is moderate to low.[10, 112]
As discussed above, the SGAHs bypass many of the side effects associated with FGAHs
due to their pharmacology. Therefore, given appropriate indication, education and
directions, SGAHs can be the preferred alternative to FGAHs in the elderly.
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however, pharmacokinetic studies loratadine and terfenadine (active metabolite of
terfenadine is fexofenadine) conducted in lactating women indicate that only minimal
amounts SGAHs is secreted in breast milk.[118, 119] Therefore, use of standard doses of
SGAHs in not likely to produce adverse effects in nursing infants.[4, 118, 119]
SGAHs, specifically loratadine and fexofenadine, are preferred over FGAHs. Citing
proven safety and effectiveness in children, WHO-collaborated guidelines, recommend
use of SGAHs for treatment of allergic rhinitis in children and recommends against the
use of FGAHs due to safety concerns, unless SGAHs are not available.[32] The same is
true for urticaria, where the use of SGAH should be primary option in children.[113] An
advantage, in addition to the low side effect profile, in the treatment of chronic urticaria
SGAHs dose may be escalated up to four times in select patients if the standard dose is
deemed ineffective; this cannot be done with FGAHs due to the possibility of fatal side
effects.[14, 113]
Despite the evidence for harm, child-friendly, flavored liquid formulations of FGAHs
continue to be marketed and promoted for use in countries such as the US.[35] However,
given the numerous adverse effects presented in this review and well established in
literature, including a recent 2012 systematic review, FGAHs should be generally
deferred in lieu of SGAHs, in children for most, if not all common indications that
require treatment with an antihistamine agent.[4, 23, 35]
Page 37 of 63
Table 11: Safety in children and breast feeding
Page 39 of 63
randomized, double- double-blind, or Placebo twice infants, No differences in all-cause or treatment-related adverse events were
blind, placebo- placebo-controlled daily orally particularly with observed between the cetirizine- and placebo-treated groups.
controlled study. study regard to central
Simons FE, et al. for 1 week. nervous system A trend was observed toward fewer adverse events and sleep-related
(2003) [122] and cardiac disturbances in the cetirizine group compared with the placebo group.
effects,
inclusive. No prolongation in the linear corrected QT interval was observed in
cetirizine-treated infants compared with either baseline values or with
values in placebo-treated infants.
Safety of Two large, double- 875 children ages 6 Fexofenadine 15, Evaluate the 5 patients on placebo and 5 on fexofenadine dropped from the studies
fexofenadine in blind, randomized, through 11 years with safety of due to adverse events not caused by study medication.
children treated for placebo-controlled, seasonal allergic Fexofenadine 30, fexofenadine
seasonal allergic parallel studies rhinitis. Incidence of adverse events was similar in active and placebo groups,
rhinitis. Fexofenadine 60 mg and did not increase with increasing fexofenadine dose: 36.2% (83 of
Graft DF, et al. 229) in the placebo group versus 35.3% (79 of 224), 36.8% (77 of
(2001) [123] or placebo twice 209), and 34.7% (74 of 213) in the 15, 30, and 60 mg twice-daily
daily for 2 weeks fexofenadine groups, respectively.
after a 1-week
placebo lead-in. Headache was the most commonly reported adverse event (6.6% in
the placebo group and 8.0%, 7.2%, and 9.4% in the 15, 30, 60 mg
twice-daily fexofenadine groups, respectively.
Page 40 of 63
VI. Cost, Regulatory and Current NEML Availability Evaluation
Table 12 below summarizes the monthly comparative costs of FGAHs and SGAHs based on
FDA approved maximum daily doses for adults for general allergic reactions. The costs for
chlorphenamine, diphenhydramine and loratadine were collected from MSH 2010 medicine
pricing reference guide for the median buyer unit price.[124] However, the costs for cetirizine,
fexofenadine and diphenhydramine oral solution were collected form Lexicomp online database,
therefore, there costs reflect US market price.[8] Monthly costs for potential tablet and solution
based treatment were calculated; no monthly costs for injection based treatment were calculated
as injections may be used only once or for acute, hospital based treatment. A literature review
looked at publications reporting costs and consequences of using FGAHs and SGAHs for the
treatment of allergic rhinitis; the review compared costs of using diphenhydramine,
chlorphenamine, cetirizine and fexofenadine.[27] The review concluded that due to the PK, PD
and resulting clinical benefits of SGAHs, their use may pose an overall economic benefit.[27]
Furthermore, given the association of lost productivity with the use of FGAHs, use of SGAHs
may prevent negative economic effects in the workplace.[101]
Table 13 below provides an overview of availability of agents under review in 15 countries with
established NEMLs retrieved from the WHO site.[125] The primary formulations of focus were
tablets (tab), injection (inj) and syrup or oral solution. Other chemicals in the 1st or 2nd generation
antihistamine class or other formulations such combination products, topical, suppositories or
extended release formulations were not considered for this survey, however, whenever possible
they were identified as follows: Fiji has promethazine, another FGAH in the injection, tablet and
suspension formulations on the formulary. India has dexchlorpheniramine suryp, pheniramine
injection and promethazine tablets and syrup on the EML; all agents are FGAHs. Kyrgyzstan has
ketotifen tab and syrup, a SGAH on NEML. Morocco has dexchlorpheniramine tablets on
NEML. Malaysia has diphenhydramine as a combination medicine for antitussive use. Nigeria
and Oman also have promethazine tablet, injection and syrup on their respective NEMLs.
Ten of the fifteen countries surveyed had at least one formulation of chlorphenamine on the
NEML; this is expected as many NEMLs are modeled after the WHO EML. Seven of the fifteen
countries had at least one formulation of diphenhydramine on the NEML. Seven countries had
both syrup and tablet formulations of loratadine and six countries had both syrup and tablet
formulations of cetirizine, and two countries had fexofenadine tablets on the NEML, for a total
of 8 countries with a SGAH on the NEML. 53% of the surveyed nations have included a SGAH
on their respective NEMLs, indicating a growing trend and necessity for these agents for patient
care, despite lack of WHO EML listing of these agents or class. However, not having an SGAH
on the EML could be a disadvantage for many nations who primarily use WHO EML to establish
their NEMLs.
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Table 12: Cost comparison of 1st and 2nd generation antihistamines
Medication (Name and Cost per Cost/30 tabs or Daily Monthly cost based on FDA TGA
Strength) unit (US$) 100mL solution or Maximum Dose maximum dosing (US$) Approved Approved
100mg inj (US$) (adult)
Chlorphenamine 4mg tab 0.0038 0.114 24mg/daily 0.684 Yes Yes
Chlorphenamine 0.0043/mL 0.43 24mg/daily 7.74 Yes Yes
2mg/5mL oral solution
Chlorphenamine 0.1470/mL 1.47 24mg/daily N/A Yes Yes
10mg/mL injection
Diphenhydramine 25mg 0.0161 0.483 200mg/daily 3.864 Yes Yes
cap
Diphenhydramine 3.1264/mL 6.25 400mg/daily N/A Yes Yes
50mg/mL injection
Diphenhydramine 0.1016/mL 10.16 200mg/daily 8.128 Yes Yes
12.5mg/5mL oral solution
Loratadine 10mg tab 0.0225 0.675 10mg/daily 0.675 Yes Yes
Loratadine 1mg/1mL 0.0055/mL 0.55 10mg/daily 1.65 Yes Yes
oral solution
Lexi-Comp online (US market price)
Cetirizine 5mg 1.000 30 10mg/daily 60 Yes Yes
Cetirizine 10mg 0.1899 5.70 10mg/daily 5.70 Yes Yes
Cetirizine 1mg/mL oral 0.1355/mL 13.55 10mg/daily 40.65 Yes Yes
solution
Fexofenadine 180mg tab 0.8663 25.99 180mg/daily 25.99 Yes Yes
Fexofenadine 30mg/5mL 0.1749 17.49 180mg/daily 157.41 Yes Yes
solution*
*Originator brand suspension for fexofenadine, all other prices are for generic products
Page 42 of 63
VII. Summary and Recommendations
This evaluation of histamine-1 receptor antagonists has illustrated in detail the evidence for
treatment of common allergic conditions with FGAH and SGAH agents as well their associated
side effect profiles. Table 2 shows the regulated and unregulated uses of antihistamine agents. In
terms of efficacy and safety, both FGAH agents are in similar standing. This evaluation has also
presented evidence of harm for all populations using FGAHs including the young and the elderly
and loss of productivity and alertness in the working groups that may result in serious, fatal
errors. The PK, PD data as well as the RCT, guidelines and the systematic review evidence
presented for FGAHs and SGAHs shows that SGAHs result in far less side effects and have
equal, if not better, efficacy than FGAHs. However, despite major safety concerns, FGAHs
mistakenly continue to be thought of as safe medications by the general population and
healthcare providers and are still used widely for a range of conditions.[35]
Economic data presented in Table 12 above indicates that the unit prices (mg and mL) for
chlorphenamine are lower than loratadine. However, according to the median buyer price from
the MSH International Drug Price Guide, the monthly cost, based on maximum doses, of
loratadine tablets and syrup are more economical than chlorphenamine.
The availability survey of 15 nations indicates that the SGAHs are already available in many
countries and the benefit of these agents should be extended to patients worldwide by listing
them on the WHO EML and EMLc.
1. Chlorphenamine may be left on the EML; there is not enough evidence to recommend a
change to diphenhydramine. Both agents appear to be equal in efficacy and safety.
a. Chlorphenamine may be retained with square box designation.
b. A change in the age restriction is recommended. Currently, chlorphenamine
recommended age is greater than 1 year. However, as the discussion above has
shown, SRAs strongly recommend against the use of FGAHs in children 6 years
of age. The age restriction of chlorphenamine should be raised to for use in
children older than 6 years only.
2. To add to the EML: Loratadine, tablet and syrup formulations. A square box designation
is recommended for loratadine, to indicate other medications in the second generation
anti-histamine class are acceptable alternatives to loratadine. Table 14 below provides the
standard FDA approved indications and doses for loratadine. Table 15 below provides
information on dose adjustments for loratadine in renal and hepatic impairments.
3. To delete from the EMLc: Chlorphenamine should be deleted from the EMLc.
Discussion above has shown that SGAHs are the preferred agents for children. And given
Page 43 of 63
the recommendation for increase in age restriction to 6 years as well as the safety
concerns regarding FGAH use in children, chlorphenamine should not be on the EMLc.
4. To add to the EMLc: Loratadine, tablet and syrup formulations. A square box designation
is recommended. Age restriction for loratadine is recommended for use against in
children younger than 2 years of age. Table 14 below provides the standard FDA
approved indications and doses for loratadine. Table 15 below provides information on
dose adjustments for loratadine in renal and hepatic impairments.
Table 14: Treatment Details for Loratadine
Page 44 of 63
Appendix
Page 45 of 63
Appendix 1 – Drug-Drug Interactions: 1st Generation Antihistamines
FGAH Interacting drug or class EML(y/n) Severity Documentation Interaction Details
Diphenhy- 1 Linezolid N Major Fair Concurrent use of DIPHENHYDRAMINE and LINEZOLID may result in increased
dramine anticholinergic toxicity effects.
2 Zolpidem / sedatives N Major Fair Concurrent use of ZOLPIDEM and SEDATIVES may result in an increase in central
nervous system depressant effects.
3 Oxycodone / sedatives N Major Fair Concurrent use of OXYCODONE and SEDATIVES may result in an increase in CNS or
respiratory depression.
4 Tapentadol sedatives N Major Fair Concurrent use of TAPENTADOL and SEDATIVES may result in an increase in central
nervous system and respiratory depression.
5 Hydromorphone / N Major Fair Concurrent use of HYDROMORPHONE and SEDATIVES may result in an increase in
sedatives CNS or respiratory depression.
6 Metoprolol Y Moderate Good Concurrent use of DIPHENHYDRAMINE and METOPROLOL may result in increased
metoprolol plasma concentration.
7 Tamoxifen Y Moderate Fair Concurrent use of DIPHENHYDRAMINE and TAMOXIFEN may result in decreased
plasma concentrations of the active metabolites of tamoxifen.
8 Clomipramine Y Moderate Fair Concurrent use of CLOMIPRAMINE and DIPHENHYDRAMINE may result in
increased anticholinergic effects (dry mouth, urinary retention).
9 Amitriptyline Y Moderate Fair Concurrent use of AMITRIPTYLINE and DIPHENHYDRAMINE may result in
increased anticholinergic effects (dry mouth, urinary retention).
10 Triflupromazine N Moderate Fair Concurrent use of TRIFLUPROMAZINE and DIPHENHYDRAMINE may result in
anticholinergic effects (dry mouth, urinary retention, altered mental status).
11 Procarbazine Y Moderate Fair Concurrent use of ANTIHISTAMINES and PROCARBAZINE may result in CNS
depression.
12 Amoxapine N Moderate Fair Concurrent use of AMOXAPINE and DIPHENHYDRAMINE may result in increased
anticholinergic effects (dry mouth, urinary retention).
13 Belladonna N Minor Fair Concurrent use of BELLADONNA and DIPHENHYDRAMINE may result in excessive
anticholinergic activity (severe dry mouth, constipation, decreased urination, excessive
sedation, blurred vision).
Chlorphe- 1 Lorcaserin N Major Fair Concurrent use of LORCASERIN and SEROTONERGIC AGENTS may result in
namine increased risk of serotonin syndrome (hypertension, tachycardia, hyperthermia,
myoclonus, mental status changes).
2 Bromocriptine N Major Fair Concurrent use of BROMOCRIPTINE and CHLORPHENIRAMINE may result in
increased risk of serotonin syndrome (hypertension, tachycardia, hyperthermia,
myoclonus, mental status changes).
3 Phenytoin Y Moderate Fair Concurrent use of PHENYTOIN and CHLORPHENIRAMINE may result in an increased
risk of phenytoin toxicity (ataxia, hyperreflexia, nystagmus, tremor).
Page 46 of 63
4 Fosphenytoin N Moderate Fair Concurrent use of FOSPHENYTOIN and CHLORPHENIRAMINE may result in an
increased risk of phenytoin toxicity (ataxia, hyperreflexia, nystagmus, tremor).
5 Procarbazine Y Moderate Fair Concurrent use of ANTIHISTAMINES and PROCARBAZINE may result in CNS
depression.
6 Belladona N Minor Fair Concurrent use of BELLADONNA and CHLORPHENIRAMINE may result in excessive
anticholinergic activity (severe dry mouth, constipation, decreased urination, excessive
sedation, blurred vision).
Definition: Severity Definition: Documentation
Contraindicated - The drugs are contraindicated for concurrent use.
Excellent Controlled studies have clearly established the existence of the
interaction.
Major - The interaction may be life-threatening and/or require medical
intervention to minimize or prevent serious adverse effects. Good Documentation strongly suggests the interaction exists,
but well-controlled studies are lacking.
Moderate - The interaction may result in exacerbation of the patient's
Fair Available documentation is poor, but pharmacologic
condition and/or require an alteration in therapy.
considerations lead clinicians to suspect the interaction exists;
or, documentation is good for a pharmacologically similar drug.
Minor - The interaction would have limited clinical effects. Manifestations
may include an increase in the frequency or severity of the side effects but Unknown Unknown.
generally would not require a Major alteration in therapy.
Unknown - Unknown.
Table created using information from Micromedex online clinical pharmacy database.[10]
Page 47 of 63
Appendix 2 – Drug-Drug Interactions: 2nd Generation Antihistamines
SGAH Interacting drug or class EML(y/n) Severity Documentation Interaction Details
Loratadine 1 Amiodarone Y Major Good Concurrent use of AMIODARONE and LORATADINE may result in
increased risk of QT interval prolongation and torsade de pointes.
2 Cimetidine N Minor Good Concurrent use of CIMETIDINE and LORATADINE may result in
increased loratadine serum concentrations; possible loratadine toxicity.
Y
Cetirizine 1 Ritonavir Y Minor Good Concurrent use of CETIRIZINE and RITONAVIR may result in increased
exposure and half-life of cetirizine as well as reduced cetirizine clearance.
Fexofenadine 1 Droperidol N Major Fair Concurrent use of DROPERIDOL and ANTIHISTAMINES may result in
an increased risk of cardiotoxicity (QT prolongation, torsades de pointes,
cardiac arrest).
2 Antacids; interacting compounds N Moderate Good Concurrent use of FEXOFENADINE and ANTACIDS may result in
-magnesium carbonate; decreased fexofenadine efficacy.
magnesium hydroxide;
magnesium trisilicate;
magnesium oxide; aluminum
carbonate, basic; aluminum
hydroxide; aluminum phosphate;
dihydroxyaluminum
aminoacetate;
dihydroxyaluminum sodium
carbonate; magaldrate
3 St John’s Wort Extract N Moderate Good Concurrent use of FEXOFENADINE and ST JOHN'S WORT may result in
decreased effectiveness of fexofenadine.
Definition: Severity Definition: Documentation
Contraindicated - The drugs are contraindicated for concurrent use.
Excellent Controlled studies have clearly established the existence of
the interaction.
Major - The interaction may be life-threatening and/or require medical intervention to
minimize or prevent serious adverse effects. Good Documentation strongly suggests the interaction exists,
but well-controlled studies are lacking.
Moderate - The interaction may result in exacerbation of the patient's condition and/or
Fair Available documentation is poor, but pharmacologic
require an alteration in therapy.
considerations lead clinicians to suspect the interaction
exists; or, documentation is good for a pharmacologically
Minor - The interaction would have limited clinical effects. Manifestations may include
similar drug.
an increase in the frequency or severity of the side effects but generally would not
require a Major alteration in therapy. Unknown Unknown.
Unknown - Unknown.
Page 48 of 63
Appendix 3 – Precautions, Contraindications and Breast Feeding Risk of 1st Generation Antihistamines
Chlorphenamine
Precautions Contraindications Breast Feeding Risk
1. Asthma 1. Hypersensitivity to 1. Avoid Breastfeeding.
2. Bladder neck obstruction chlorpheniramine or 2. Infant risk cannot be ruled out.
3. Hepatic insufficiency dexchlorpheniramine 3. Available evidence and/or expert
4. Narrow-angle glaucoma consensus is inconclusive or is inadequate
5. Pyloroduodenal obstruction for determining infant risk when used
6. Sedative effects; some patients may be more or less during breastfeeding. Weigh the potential
susceptible benefits of medication treatment against
7. Stenosing peptic ulcer potential risks before prescribing this
8. Symptomatic prostatic hypertrophy medication during breastfeeding.
Diphenhydramine
Precautions Contraindications Breast Feeding Risk
1. Bladder neck obstruction 1. Hypersensitivity to 1. Milk effects are possible.
2. Concurrent maoi therapy diphenhydramine 2. Evidence suggests this medication may
3. Concurrent use of central nervous system depressants 2. Newborns or premature infants alter milk production or composition. If
4. Decreases mental alertness and psychomotor performance 3. Nursing mothers an alternative to this medication is not
5. Do not use topical form on eyes or eye lids prescribed, monitor the infant for adverse
6. Elderly are more susceptible to the side effects of effects and/or adequate milk intake.
diphenhydramine
7. History of bronchial asthma, increased intraocular pressure,
hyperthyroidism, cardiovascular disease or hypertension
8. May cause excitation in young children
9. Narrow angle glaucoma
10. Pyloroduodenal obstruction
11. Stenosing peptic ulcer
12. Symptomatic prostatic hypertrophy
13. Use of the topical form on patients with chicken pox,
measles, blisters, or large areas of skin unless directed by a
physician
Table based on clinical information from Micromedex clinical pharmacy database.[10]
Page 49 of 63
Appendix 4 – Precautions, Contraindications and Breast Feeding Risk of 2nd Generation Antihistamines
Loratadine
Precautions Contraindications Breast Feeding Risk
1. Impaired liver function 1. Hypersensitivity to loratadine or any of its 1. Maternal medication usually compatible with
2. Impaired renal function ingredients breastfeeding.
3. Pregnancy 2. Hypersensitivity to desloratadine, an active 2. Infant risk is minimal.
metabolite of loratadine 3. The weight of an adequate body of evidence
and/or expert consensus suggests this
medication poses minimal risk to the infant
when used during breastfeeding.
Cetirizine
Precautions Contraindications Breast Feeding Risk
1. Activities requiring mental alertness 1. Hypersensitivity to cetirizine, levocetirizine (R 1. Infant risk cannot be ruled out.
2. Concurrent use of central nervous system enantiomer of cetirizine hydrochloride), or 2. Available evidence and/or expert consensus
depressants components is inconclusive or is inadequate for
3. Elderly 2. Hypersensitivity to hydroxyzine determining infant risk when used during
4. Hepatic dysfunction breastfeeding. Weigh the potential benefits of
5. Renal insufficiency medication treatment against potential risks
before prescribing this medication during
breastfeeding.
Fexofenadine
Precautions Contraindications Breast Feeding Risk
1. Concurrent administration of aluminum- and 1. Hypersensitivity to fexofenadine or any of the 1. Maternal medication usually compatible with
magnesium-containing antacid within 15 ingredients breastfeeding.
minutes; decrease fexofenadine absorption 2. Infant risk is minimal.
2. Concurrent consumption of fruit juices, such 3. The weight of an adequate body of evidence
as grapefruit, orange, and apple; decrease and/or expert consensus suggests this
fexofenadine bioavailability and exposure medication poses minimal risk to the infant
when used during breastfeeding.
Table based on clinical information from Micromedex clinical pharmacy database.[10]
Page 50 of 63
Appendix 5: Non-allergic conditions treated with Antihistamines
Since motion sickness is a centrally mediated event, requiring anti-cholinergic activity of the
antihistamines, SGAH are not effective in this respect.[129]
B. Antitussive uses
Diphenhydramine is commonly used as an antitussive agent, although the exact mechanism
for cough suppression has yet to be elucidated.[10, 132] However, it is believed that the
antitussive effect is likely due to action in the central nervous system on the medullary cough
center.[10] While mechanisms peripherally in the body may also be involved, there is not
enough data to firmly make this determination.[10] Studies in animals indicate efficacy for
antitussive activity of diphenhydramine, however, there is lack of supporting data in
humans.[10] In a double-blind study, 13 adults with chronic bronchitis were treated with 25
or 50 mg of diphenhydramine every 4 hours for four doses indicating statistically and
clinically significant reduction in the frequency of coughs with both doses when compared to
placebo.[10, 132] However, half of the participants in the study continued to cough
frequently, with the most frequent side effect of drowsiness, particularly with the 50 mg dose
of diphenhydramine.[10] It should be noted that diphenhydramine is an anti-cholinergic
agent that may lead to thickening of bronchial secretions complicating care of asthmatic
patients since the anticholinergic effects may make secretions more difficult to
expectorate.[10] However, FDA advisory review panel considers diphenhydramine, like
codeine and dextromethorphan, as a safe and effective antitussive agent but with higher
incidence of side-effects.[10] Furthermore, both dextromethorphan and codeine are
considered to be effective medications to alleviate cough; while dextromethorphan profile
Page 51 of 63
indicates it is not likely for the user to become dependent on it or cause respiratory
depression, both of which are concerns for codeine.[10, 133] Moreover, given its wide safety
and toxicity index, dextromethorphan is considered to be the safest antitussive available,
leaving little use for FGAHs in this respect.[10]
A non-blind, randomized clinical trial for 139 children aged 24-60 months, suffering from
cough due to upper respiratory airway infections (URI), compared cough suppressant effects
of 2.5mLs of honey, dextromethorphan and diphenhydramine.[134] The study found that
honey was significantly more effective at suppressing URI-associated cough than
dextromethorphan or diphenhydramine.[134] However, a Cochrane review found that honey
may be better at cough suppression than ‘no treatment’ or diphenhydramine, but not better
than dextromethorphan.[133] Furthermore, if the URI is due to a viral cause, the cough
would not be histamine mediated; therefore, FGAHs may not be effective in alleviating the
cough.[135]
SGAHs do not cross the blood-brain-barrier readily, therefore, their effect on the medullary
cough centers of the brain would be limited, possibly non-existent, providing no indication
for antitussive use.[3, 5, 23]
Given that honey may be more effective at cough suppression than diphenhydramine, with
none of the FGAH associated side-effects and dextromethorphan as the most effective
treatment – it can be argued that antihistamine should not be considered for antitussive use if
alternatives are available.
Page 52 of 63
FGAHs including with the use of positron emission tomography (PET scans).[35, 87, 138]
This hangover effect directly leads to subjective reporting of sleepiness, objectively observed
sleepiness and decline in psychomotor performance the day after administration of
diphenhydramine as a sleeping aid.[138] However, no similar side-effects were observed
with another sleep-aid, zolpidem.[138] Furthermore, the use of diphenhydramine has not
been shown to result in improved sleep.[139, 140] And there are conflicting reports on the
ability of habitual users of FGAHs to develop tolerance to daytime sedation and psychomotor
impairment.[35, 141, 142]
Given the poor efficacy and safety profile of FGAHs for this indication, it is concluded that,
when available, other agents, such as zolpidem should be considered for patients suffering
from insomnia.
SGAHs are not as capable of crossing the blood-brain-barrier as FGAHs, therefore, their use
in insomnia would not be indicated.[3, 5, 23]
D. Extrapyramidal Symptoms
Extrapyramidal symptoms (EPS) consist of a constellation of symptoms known as dystonic
reactions, akathisia, and pseudoparkinsonism thought to be the result of antagonism of
central dopamine receptors.[10, 143, 144] These symptoms of EPS are commonly associated
with use of antipsychotic agents and the severity and development of EPS is generally dose
related, however, dystonias may also be of idiopathic origin.[10, 143-147] EPS symptoms,
such as dystonias from use of antipsychotic medications or idiopathic origin can be managed
with anticholinergic agents including intramuscular or oral diphenhydramine.[10, 17, 144,
146-149] However, there are many other treatment options for dystonias such as benztropine,
biperiden, ethopropazine, orphenadrine, procyclidine, trihexyphenidyl, amantadine, or
benzodiazepines.[10, 148] Treatment of akathisia with anticholinergic, on the other hand, is
generally not successful.[10] A change in the antipsychotic dose is considered to be the most
effective treatment in alleviating this symptom of EPS; conversely switching the patient to a
lower-potency antipsychotic agent may also resolve the symptoms.[10] Pseudoparkinsonism
is associated particularly with use of high-potency antipsychotic agents, increasing age and
female patients, is effectively treated with anticholinergic agents such as diphenhydramine,
benztropine, trihexyphenidyl, and biperiden.[10, 148, 150] Benztropine is the preferred
anticholinergic agent due to its long half-life allowing for once or twice daily dosing while
diphenhydramine would need to be administered three times a day.[10]
Given the availability of alternative, effective treatments for EPS, FGAHs should not be
considered first line therapy for management of EPS. Due to the inability of SGAHs to cross
the blood-brain-barrier, their effectiveness in treatment of EPS is limited.[3, 5, 23]
Page 53 of 63
Appendix 6: EML Application Sections
1. Summary statement of the proposal for inclusion, change or deletion
2. Name of the focal point in WHO submitting or supporting the application (where
relevant)
None
5. Formulation proposed for inclusion; including adult and pediatric (if appropriate)
See section: VII Summary and Recommendations on page 43 and Table 14:
Treatment Details for Loratadine on page 44.
See section VI Cost, Regulatory and Current NEML Availability Evaluation on page
41 and Table 12: Cost comparison of 1st and 2nd generation antihistamines and Table
13: Availability of reviewed medications on NEMLs of 15 nations on page 42.
9. Treatment details (dosage regimen, duration; reference to existing WHO and other
clinical guidelines; need for special diagnostics, treatment or monitoring facilities and
skills)
See section: VII Summary and Recommendations on page 43 and Table 14:
Treatment Details for Loratadine on page 44.
Page 54 of 63
10. Summary of comparative effectiveness in a variety of clinical settings:
See the following:
Table 4: Efficacy and side-effects of FGAHs in Allergic Rhinitis and Urticaria on
page 15
Table 5: Guidelines on Treatment of Allergic Rhinitis on page 18
Table 6: Efficacy and safety of SGAH in Allergic Rhinitis on page 19
Table 7: Guidelines and Systematic Reviews on Treatment of Urticaria on page
24
Table 8: Efficacy and Safety of SGAHs in Urticaria on page 25
12. Summary of available data on comparative cost and cost-effectiveness within the
pharmacological class or therapeutic group:
See section VI Cost, Regulatory and Current NEML Availability Evaluation on page
41 and Table 12: Cost comparison of 1st and 2nd generation antihistamines on page
42
13. Summary of regulatory status of the medicine (in country of origin, and preferably in
other countries as well)
See section VI Cost, Regulatory and Current NEML Availability Evaluation on page
41 and Table 12: Cost comparison of 1st and 2nd generation antihistamines on page
42
See section VI Cost, Regulatory and Current NEML Availability Evaluation on page
41 and Table 12: Cost comparison of 1st and 2nd generation antihistamines on page
42
See section: VII Summary and Recommendations on page 43 and Table 14:
Treatment Details for Loratadine on page 44.
Page 55 of 63
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