Medication Use in Elderly Patients

Anticholinergic Medications

• Hydroxyzine should be avoided in elderly patients due to its strong anticholinergic properties, increased risk of falls, cognitive impairment, and sedation, as recommended by the American Geriatrics Society 1, 2
• Patients with renal impairment should use loratadine and desloratadine with caution, as they may be affected by severe renal impairment, and those with hepatic impairment may need dosage adjustments, according to guidelines from 3

Second-Generation Antihistamines

• Elderly patients are more sensitive to psychomotor impairment and at increased risk for complications like falls when taking second-generation antihistamines 4, 5
• Second-generation antihistamines like loratadine are strongly preferred over first-generation antihistamine combinations like Actifed for routine allergy treatment, as recommended by the American Academy of Allergy, Asthma, and Immunology 4
• Loratadine 10 mg can be administered once daily in the morning, as recommended by guidelines from the American Academy of Allergy, Asthma, and Immunology 6, 4
• The American Academy of Allergy, Asthma, and Immunology recommends loratadine as a first-line treatment for severe allergic rhinitis or urticaria symptoms when anaphylaxis is not a concern, due to its favorable safety profile, once-daily dosing, and non-sedating properties 7

Sedation Potential of Antihistamines

• Second-generation antihistamines have varying degrees of sedation potential, with fexofenadine, desloratadine, and loratadine being non-sedating at recommended doses, and cetirizine and intranasal azelastine being potentially sedating, as recommended by the American College of Allergy, Asthma, and Immunology and the American Academy of Allergy, Asthma, and Immunology 4
• The sedative potential of various antihistamines is compared in the following table:

4

• Sedative antihistamines long term may predispose to dementia and should be avoided, except in palliative care, as noted by the British Association of Dermatologists 8

Management of Pruritus and Nasal Congestion

• For patients with severe nasal congestion, intranasal corticosteroids are typically more effective than either antihistamines or decongestants alone, as suggested by the American Academy of Allergy, Asthma, and Immunology 4
• High lipid content moisturizers should be applied daily to manage pruritus in older adults, as recommended by the British Journal of Dermatology, with a focus on xerosis (dry skin) which affects a significant portion of elderly patients 8
• The British Journal of Dermatology recommends applying hydrocortisone to affected areas up to 3-4 times daily for 2 weeks to help rule out and treat underlying asteatotic eczema in older adults with pruritus 8
• Combination Therapy, including H1 and H2 antagonists together (e.g., fexofenadine with cimetidine), is also recommended by the British Journal of Dermatology for pruritus management in older adults 8

Pseudoephedrine Use

• Patients with severe renal impairment should use loratadine and desloratadine with caution, and patients with certain conditions, such as hypertension, glaucoma, and hyperthyroidism, should avoid pseudoephedrine 3, 4
• Combination products containing pseudoephedrine, such as antihistamine-decongestant combinations, should be avoided as they may increase the risk of cardiovascular side effects, according to the American Academy of Allergy, Asthma, and Immunology 4
• Pseudoephedrine can cause insomnia, irritability, palpitations, and has the potential to increase blood pressure, and patients should be monitored for blood pressure changes when using pseudoephedrine, particularly those with controlled hypertension 4