Antihistamines Cocktail

[GummyRPh]

Got a prescription today for a patient: Allegra 60 mg BID, Claritin (dose not specified) qd, and Atarax 50 mg QHS. Called MD to clarify why three antihistamines. At first he told me to just dispense. After I pushed for a justification, he said, "Have you seen how swollen the patient was? He needs all those medications!". I tried further to argue that even with allergic reactions the patient will get more harm from side effects than benefits from three antihistamines together. But his only reply was, "are you the one seeing the patient or no?".

My understanding is that if a patient has allergies so severe that he swells up, he needs epi pen injections instead of taking a bunch of antihistamines at once. Has anyone encounter literatures supporting the use of multiple antihistamines to treat allergic reactions? If you were in my situation, would you still dispense the meds after the doctor insist that you do?

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[zelman]

Got a prescription today for a patient: Allegra 60 mg BID, Claritin (dose not specified) qd, and Atarax 50 mg QHS. Called MD to clarify why three antihistamines. At first he told me to just dispense. After I pushed for a justification, he said, "Have you seen how swollen the patient was? He needs all those medications!". I tried further to argue that even with allergic reactions the patient will get more harm from side effects than benefits from three antihistamines together. But his only reply was, "are you the one seeing the patient or no?".

My understanding is that if a patient has allergies so severe that he swells up, he needs epi pen injections instead of taking a bunch of antihistamines at once. Has anyone encounter literatures supporting the use of multiple antihistamines to treat allergic reactions? If you were in my situation, would you still dispense the meds after the doctor insist that you do?

Using a first and second generation antihistamine together is appropriate. For a severe prolonged allergic response, it is a good idea to use a strong fast-acting agent like benadryl and a long acting agent like claratin. Repeated benadryl doses would be therapeutically superior, but at the cost of poor adherence and greater side effects (anticholinergic and sedation). Claritin is the drug of choice when trying to avoid adverse effects, but for situations more intense than seasonal allergies (e.g. dermatographism) the dose is typically doubled. Higher doses increase likelihood of adverse effects (mostly sedation), but claritin is still your best option. If this isn't strong enough, a normal daily dose of two second generation agents might be a better option (when one of them is claritin) than doubling up on a single agent with more incidence of adverse effects. Since this prescriber went with allegra 60mg BID instead of 180mg QD, it seems like that's what they're going for.

As long as the patient has tried 20mg of claritin QD first, the prescribed regimen seems fine for that sort of situation. But that situation is somewhat rare, so I'd dispense and discuss with the patient.

 

[Pharmavixen]

If the pt is this badly off, surely a short course of prednisone makes better sense.

 

[WVUPharm2007]

If the pt is this badly off, surely a short course of prednisone makes better sense.

Yeah, pretty much. Doc is cray cray.

 

[klaurent02]

As a patient I would always avoid taking a drug like prednisone whenever possible.

 

[Pharmavixen]

Histamine is only one of the mediators of the inflammatory response implicated in allergic reactions. So antihistamines don't do anything about the proinflammatory cytokines, leukotrienes & prostaglandins. And loading someone up with antihistamines is only exposing them to more side effects without any further therapeutic benefits beyond a ceiling.

As an asthmatic I can relate to steroid aversion and for many years tried to skimp on my use of ICS out of fear of long-term consequences. But I was exposing myself to the risk of airway remodeling from under-treated asthma.

Short-course prednisone won't harm you and may save your life.

 

[ancienbon]

Got a prescription today for a patient: Allegra 60 mg BID, Claritin (dose not specified) qd, and Atarax 50 mg QHS. Called MD to clarify why three antihistamines. At first he told me to just dispense. After I pushed for a justification, he said, "Have you seen how swollen the patient was? He needs all those medications!". I tried further to argue that even with allergic reactions the patient will get more harm from side effects than benefits from three antihistamines together. But his only reply was, "are you the one seeing the patient or no?".

My understanding is that if a patient has allergies so severe that he swells up, he needs epi pen injections instead of taking a bunch of antihistamines at once. Has anyone encounter literatures supporting the use of multiple antihistamines to treat allergic reactions? If you were in my situation, would you still dispense the meds after the doctor insist that you do?

I think predinisone should be a better choice . The antihistamines wont do anything for the inflammation. I would keep the atarax at bedtime.

 

[npage148]

Doctors use some of the wackiest pseudo-pharmacology to justify their weird prescribing habits.

 

[txpharmguy]

I'm surprised that an H2 blocker wasn't added as well. I've seen many emergency room physicians write for those too following an allergic reaction.

 

[MindOverMatter]

I'm surprised that an H2 blocker wasn't added as well. I've seen many emergency room physicians write for those too following an allergic reaction.

I've seen this a lot too. Atarax, famotidine, and Claritin for a rash, with a little clobetasol cream sprinkled in for good measure.

I would call on the Allegra and Claritin combo too. Or just tell the patient to only take the Claritin.

 

[WVUPharm2007]

Just give the person prednisone, cetirizine (isn't it the one with the best dermal availability or is my brain making that up?), cimetidine, montelukast, topical diphenhydramine, and some Robitussin. Boom, fizzixed.

 

[npage148]

Don't forget Xolair to sop up the IgE

 

[BidingMyTime]

I'm surprised that an H2 blocker wasn't added as well. I've seen many emergency room physicians write for those too following an allergic reaction.

I concur. I see minimal benefit to giving 3 antihistimines (a bit of benefit giving a long-acting with a short acting one.) It makes more sense to add an H2 antagonist & a steroid.

 

[psychoandy]

Got a prescription today for a patient: Allegra 60 mg BID, Claritin (dose not specified) qd, and Atarax 50 mg QHS. Called MD to clarify why three antihistamines. At first he told me to just dispense. After I pushed for a justification, he said, "Have you seen how swollen the patient was? He needs all those medications!". I tried further to argue that even with allergic reactions the patient will get more harm from side effects than benefits from three antihistamines together. But his only reply was, "are you the one seeing the patient or no?".

My understanding is that if a patient has allergies so severe that he swells up, he needs epi pen injections instead of taking a bunch of antihistamines at once. Has anyone encounter literatures supporting the use of multiple antihistamines to treat allergic reactions? If you were in my situation, would you still dispense the meds after the doctor insist that you do?

don't take this the wrong way, but did you suggest other alternatives? one of my biggest pet peeves is when a pharmacist says "no you shouldn't do this" but then uses "side effects" as an excuse and also doesn't have a reasonable alternative (eg add steroid, d/c clartin and increase allegra, etc). happens a lot more frequently than i'd like to see.

anyways, dual 2nd gen + 1st gen qhs is kinda silly but not life threatening.

epi pens should be for acute anaphylaxis and using one pretty much means you're going to the ER, so i doubt their allergy was that bad. not to mention you know how much they cost. steroids sound indicated and it's really weird that they didn't try that.

also lol xolair gl with that PA

 

[meister]

Allergists use high doses of anti-histamines for chronic urticaria all the time, and if this guy was an allergist he was probably doing so to avoid giving Xolair.

Was the guy an allergist?

 

[WVUPharm2007]

Allergists use high doses of anti-histamines for chronic urticaria all the time, and if this guy was an allergist he was probably doing so to avoid giving Xolair.

Was the guy an allergist?

And some neurologists tell their patients that idiotic myth about how generic drugs have "20% less drug" in them and write for brand Topamax all the time, too. Just because they do it doesn't make it logical or supported by evidence. There are physicians that hide behind the ridiculous assertion that because they are specialists they are the utmost highest authority on everything way too much. "But I'm a specialist." Yeah, good for you...you're specialist that's too ****ing lazy to read medical journals. (Not saying all specialists are like this at all, its a certain, lazy, minority.)

 

[JoBreeze]

tried further to argue that even with allergic reactions the patient will get more harm from side effects than benefits from three antihistamines together.

Can't make that call based on the limited information given.

 

[meister]

And some neurologists tell their patients that idiotic myth about how generic drugs have "20% less drug" in them and write for brand Topamax all the time, too. Just because they do it doesn't make it logical or supported by evidence. There are physicians that hide behind the ridiculous assertion that because they are specialists they are the utmost highest authority on everything way too much. "But I'm a specialist." Yeah, good for you...you're specialist that's too ****ing lazy to read medical journals. (Not saying all specialists are like this at all, its a certain, lazy, minority.)

Except the comparison you're making is illogical and not applicable to the situation I'm describing, because dose escalation of H1-antagonists is a well known and accepted treatment option for chronic urticaria that is refractory to initial doses. The only lazy practitioner I'm seeing is yourself, thanks.

 

[WVUPharm2007]

Except the comparison you're making is illogical and not applicable to the situation I'm describing, because dose escalation of H1-antagonists is a well known and accepted treatment option for chronic urticaria that is refractory to initial doses. The only lazy practitioner I'm seeing is yourself, thanks.

Yeah, ok, Gilligan.

If you read the post, my point is that you shouldn't just justify things with "because its what allergists do." If there are guidelines supporting whatever, fine. Like I typed, there are way too many specialists that roll out their anecdotal evidence as fact. (Not say there are a ton of them, just that one is way too many.) Just because one is an allergist doesn't automatically make them right and the end all be all.

Though I do wonder why both allegra and claritin.

 

[Pharmavixen]

Allergists use high doses of anti-histamines for chronic urticaria all the time, and if this guy was an allergist he was probably doing so to avoid giving Xolair.

Was the guy an allergist?

What Mike says. And like I mentioned in a previous post, histamine is only one mediator of many implicated in allergic reactions. Just because allergists use high doses of antihistamines for urticaria doesn't mean it's evidence-based.

The whole "it was ordered by a specialist" thing gets up my nose, too. Like when guys come back from hospital after an eye injury with an rx for moxifloxacin eye drops, and I say, we have ofloxacin, so we're good. And the nurses say, "But it was ordered by an OPHTHALMOLOGIST!!!"

Claritin + Allegra = dr who doesn't understand pharmacology. Don't matter how long he spent in school.

I am old enough to remember medicine before Sackett, and what evidence-based medicine basically does is protect patients from the arrogance of specialists.

 

[npage148]

Dermatology is a speciality that is defined by doing stupid things and then hiding behind the title. I agree that being a specialists doesn't make you immune from prescribing inapprpriately.

 

[meister]

Specialists hide behind their title, pharmacists hide behind their counter.

There aren't any great RCTs of high dose anti-histamines that I know of but the lack of that level of evidence doesn't mean it doesn't work or precludes one from trying it anyway. In fact it's well accepted practice within the literature to do so in refractory cases.

As far as why the patient had both Claritin and Allegra scripts, who knows, maybe he/she told the patient to try one and if it doesn't work to try the other. Impossible to say from the confines of a CVS drive-thru window though, that's for sure. Unless you just love being judgmental and arrogant.

 

[npage148]

Specialists hide behind their title, pharmacists hide behind their counter.

There aren't any great RCTs of high dose anti-histamines that I know of but the lack of that level of evidence doesn't mean it doesn't work or precludes one from trying it anyway. In fact it's well accepted practice within the literature to do so in refractory cases.

As far as why the patient had both Claritin and Allegra scripts, who knows, maybe he/she told the patient to try one and if it doesn't work to try the other. Impossible to say from the confines of a CVS drive-thru window though, that's for sure. Unless you just love being judgmental and arrogant.

Struck a nerve I see. Don't like your ego being questioned? Make sure to not thank the pharmacist when they prevent you from killing one of your patients, just huff and hang up

 

[JoBreeze]

What's the difference between the doctors who follow your example:

Make sure to not thank the pharmacist when they prevent you from killing one of your patients, just huff and hang up

and the pharmacist who makes the statement:

Dermatology is a speciality that is defined by doing stupid things and then hiding behind the title.

?

You are a hypocrite.

 

[BenJammin]

Specialists hide behind their title, pharmacists hide behind their counter.

There aren't any great RCTs of high dose anti-histamines that I know of but the lack of that level of evidence doesn't mean it doesn't work or precludes one from trying it anyway. In fact it's well accepted practice within the literature to do so in refractory cases.

As far as why the patient had both Claritin and Allegra scripts, who knows, maybe he/she told the patient to try one and if it doesn't work to try the other. Impossible to say from the confines of a CVS drive-thru window though, that's for sure. Unless you just love being judgmental and arrogant.

So, Mr Pharmacist, you allowed this prescription to go through to the patient? Even though you know that, although there is some use in urticaria, there is no acceptable reason for a patient to be prescribed these drugs in the way they were prescribed? Oh, so the doctor wouldn't tell you the diagnosis. So without a diagnosis, you can't really say whether or not this is appropriate? But you filled it anyway causing the patient to....

Ladies and gentlemen of the jury, it is clear who is at fault and your judgement today should reflect that.