Dr. Anna Wolfson observes a concerning trend regarding the allergy medication diphenhydramine in her clinic daily.
“When someone experiences an allergic reaction to food, the common statement is, ‘Don’t worry, I have diphenhydramine in my bag,’” Wolfson noted, emphasizing, “But really, epinephrine is the first-line treatment for food allergies.” She works as an allergist at Massachusetts General Hospital.
She highlights the potential dangers of administering diphenhydramine after a food allergy reaction. This medication, known widely as Benadryl, can induce drowsiness, leading individuals to overlook worsening symptoms.
“We really need to move on from this. For every use of diphenhydramine, there are more effective and safer medications available,” she said. “I’ve had patients where I was genuinely concerned that diphenhydramine affected their driving ability or impacted their daily lives.”
Wolfson’s opinion isn’t isolated. Allergy specialists from Johns Hopkins University and the University of California, San Diego have recently suggested discontinuing the sale of diphenhydramine in both over-the-counter and prescription forms in the U.S., labeling it as outdated and risky compared to newer, safer alternatives.
Since its approval in 1946, diphenhydramine has gained popularity as a remedy for allergies, sleep disturbances, and cold symptoms. The American Pharmacists Association notes that usage tends to peak in summer, as people reach for it to tackle itching from insect bites or rashes caused by poison ivy, alongside sneezing and runny noses due to pollen allergies.
However, the authors of the new review caution about its disproportionate risks, particularly for children and older adults, compared to more modern antihistamines.
According to Dr. James Clark from Johns Hopkins, alternatives like loratadine (Claritin), cetirizine (Zyrtec), or fexofenadine (Allegra) should be tried for allergy symptoms.
The Consumer Healthcare Products Association, representing the OTC medicine sector, maintains that the common side effects of diphenhydramine are outlined on the label, stressing these products aren’t meant for long-term use.
“When used as directed, these medications have proven benefits for common health issues like allergies, colds, and minor irritations,” it stated on behalf of Benadryl’s manufacturer, Kenvue. “As with all medications, responsible use is crucial. Consumers should adhere to the directions and consult healthcare providers with any queries.”
Risks of diphenhydramine
These antihistamines function by blocking H1 receptors, part of the body’s allergic response system that leads to symptoms like sneezing and runny noses. Yet, older medications like diphenhydramine not only inhibit those specific receptors but can also impact other brain functions. This often results in sedation, cognitive issues, and in more serious cases, heart problems, as the authors noted.
For older adults, diphenhydramine can remain in the system for up to 18 hours, causing extended drowsiness, confusion, and a higher risk of falls. The review pointed out potential associations between long-term use of diphenhydramine and dementia.
Children may experience even greater risks. The review highlighted instances of accidental overdoses, unexpected reactions like agitation or extreme sedation, and even fatalities tied to pediatric formulations, particularly during the TikTok-related “Benadryl Challenge.”
Dr. Manuela Murray, a pediatrician at the University of Texas Medical Branch, cautioned against casual use of diphenhydramine.
“It should always be administered under professional guidance and is really only appropriate for allergic reactions and motion sickness,” Murray conveyed in an email.
She added that it’s often misapplied and “doesn’t aid cold symptoms effectively, nor is it a safe sleep aid.” In children, it can sometimes lead to heightened activity instead.
Dr. Alyssa Kuban, a pediatrician and associate medical director at Texas Children’s Pediatrics, echoed these concerns, stating she frequently sees families using diphenhydramine for colds, believing it will ease congestion and help with sleep, which isn’t effective or safe.
She advocates for over-the-counter cetirizine to support children experiencing hives or seasonal allergies, noting it lasts longer and is less sedating than diphenhydramine.
Murray also supports the use of loratadine and cetirizine for children over six months, and recommends saline drops for infants.
‘Time to say a final goodbye’
Diphenhydramine is present in over 300 OTC products, often combined with other medications for coughs and colds. The review’s authors suggest it should at least be kept behind the pharmacy counter, enabling pharmacists to direct patients to safer alternatives.
The American Pharmacists Association encourages vigilance regarding combination products containing diphenhydramine.
Pharmacists can help recommend suitable alternatives for older adults sensitive to certain medications and encourage patients to seek tailored treatment with minimal side effects.
The review also emphasized the lack of solid clinical evidence supporting diphenhydramine’s efficacy over other treatments. While it may alleviate symptoms like sneezing, it offers little relief for nasal congestion and doesn’t perform better than newer medications in trials. Newer options, like oral cetirizine, provide longer-lasting relief with fewer side effects.
Nevertheless, in the U.S., diphenhydramine remains a familiar choice. The review indicates that over 1.5 million prescriptions are still written yearly, excluding untracked OTC purchases.
“While it has historically been a helpful medication for many, its effectiveness has been surpassed by newer antihistamines, especially given their significantly reduced adverse reactions. It’s time to bid farewell to diphenhydramine, a public health risk,” the authors concluded.
