Bendaryl vs. Epi ... help!

[ctmartin]

Hi Everyone,

I have most recently been posting on the reactions page because my daughter had a severe reaction requiring epi last week.  In the aftermath, I spoke with a nurse practitioner at Duke today (my daughter's allergist, Dr. Burks, is no longer at Duke and they have yet to replace him) and asked her questions that I had hoped would make me more certain on my course of action next time.  However, the info I received was even more confusing  to me!

I have always been under the impression that benadryl does not *stop* a reaction in its tracks (only epi does) ... that it would only treat the symptoms.  Obviously, considering the fact that my daughter's reaction, untreated, progressed to anaphylaxis, the administration of the epi pen became necessary.  HOWEVER, the nurse practitioner was surprised that I had not given benadryl when I first suspected a reaction.

The reason I did not (besides the fact that we did not have benadryl in the house ... now we do), is because I wasn't completely sure a reaction was taking place and I was afraid  to administer benadryl and (1) possibly mask the symptoms, only to have them return later with a vengeance once the antihistamine wore off and (2) risk the possibility of her becoming sleepy where i couldn't monitor her sufficiently (the nurse's response to this was that surely she would wake up if she were having difficulty breathing, but the thought of that terrifies me, not to mention the trouble that might be caused if her GI symptoms reoccurred while she was sleeping and she ended up vomiting and possibly choking on it!!).

She told me that most reactions resolve with an antihistamine, and if I was worried about drowsiness I could give zyrtec instead.  Has anyone else ever heard this?  Now keep in mind, we did not know at the time what she was reacting to, so technically there was "no known ingestion."  I just think it seems giving benadryl is really risky, however, maybe I am wrong and if I had administered it before we were in emergency mode (i.e. head to toe hives, coughing and wheezing), epi might not have been needed?

Also, she told me that it is time to get Epi, rather than Epi Jr., but the packaging says 65 pounds for Epi, and my daughter is only 44 (she is at the borderline of when Duke suggests changing over).  When I asked the nurse if there would be a problem administering too much epi, she said she didn't "expect" there would be.  Didn't sound too sure to me!

Any info, comments, anecdotes greatly appreciated.  I am going to try to research these issues with different allergists and see what the consensus agrees on (if there could possibly be a consensus on these types of things!)  Thanks!!

[CMdeux]

I suspect that you may be as knowlegeable as the pros on this one, since this is largely a matter of pharmacology rather than established medical practice.

KWIM?

Yes, diphenhydramine is sedating.  Second gen antihistamines aren't, and some (fexofenadine and cetirizine in particular) are great at treating cutaneous symptoms in particular... BUT... they don't hit both receptor subtypes, which means that they don't put any kind of damper on GI stuff the way the sedating ones do.  Oh-- and for that reason, benadryl works a TREAT for treating nausea and other GI stuff even if it's viral.

Can it "stop" progression during a major reaction, though?

The jury is still out on this one.  The pharmacology suggests not, but there is puhhhhhlenty that isn't known about food anaphylaxis in particular.  There are a LOT of mechanstic feedback points in this particular IgE-mediated second messenger cascade.  The problem is that because some of those connection points are relatively unexplored, the answer is far from clear as to what impact receptor blockade has.  Certainly benadryl won't STOP anaphylaxis in progress.  Not once it has developed CNS features, anyway, and those are what tends to kill.  For that reason, there's NO WAY that it's a lifesaving medication.

On the other hand, is there harm in administering it promptly during a suspected/possible reaction? 

I don't think that there is.  It's what we've done for years. 

Has it "prevented" more severe reactions?  Probably not, but maybe it has prevented us from a few ER visits which were borderline (grade II to grade III without airway or cardiovascular symptoms).  <shrug>  Remember, most anaphylaxis self-resolves.  How much is "most?"  Well, nobody knows.  Obviously there is a vexing problem with collecting good data on that one.   

Has it "masked" more seriouc symptoms?

Absolutely NOT.   The dosing window is so wide for benadryl that even though it has sedating effects, most of us aren't going to err significantly enough to harm our kids by giving it... and honestly, like any of us are going to let our kids out of arms reach once we've given a dose or two of benadryl, right?  So I'm not too worried about her being sleepy.  I'll be alert enough for both of us, basically.  LOL.  BTDT, spent a NUMBER of nights watching over a benadryl-dosed, sleeping child.  Even up until she was 12.

DD has been given enormous doses of Zyrtec by her allergist, but only because they kept samples on hand, and didn't for OTC benadryl. 


I know that we have a couple of threads down in RXNs about the pharmacological mechanistics of all of this.  One is about diphenhydramine and the other is about epinephrine.

[CMdeux]

Oh, DD was moved from epi jr to epi at about 45 lbs, as well.  The justification was that she had severe reaction history, so was likely to need the medication in the future.  Overdosing carries a small risk of intercranial hemorrhage, but that is obviously not a great concern relative to the risks of underdosing.



(GGA.... ETC spelling.  Atrocious.)

[hezzier]

I can only speak to what our allergist has advised us on our emergency action plan, but we can give benadryl for a skin only reaction and we are to epi for everything else.  From the reading I've done on this website, it sounds as if the nurse is behind the times in terms of where the general trend of treatment is going.

We switched over to the regular epi when DS was a hair below 50 lbs, basically because it was the prescription that would last for this whole school year and it seems wasteful to get Jr's for a couple months and then switch.

[socks on a rooster]

I've read that some allergists are not including Benadryl in emergency plans as much because of a tendency to rely on it using the wait and see approach. We still use it at the beginning of what seems to be a reaction (single body system symptoms). The last time dd had anaphylaxis she was given Benedryl at school for an itchy mouth. She was observed for 20-30 minutes and returned to class feeling fine. By the time I picked her up from school perhaps an hour later and got home, she developed stridor (no other symptoms at all). It makes me think that without the Benedryl it would have been a faster reaction, so in a sense, it maybe did "mask" a reaction if that is what you want to call it. I'm sorry about her reaction, I'll go to the reactions board to see what happened. 

[Mfamom]

The way I look at it is that it is better to be safe than sorry.  I've had 2 appts with Dr. Sicherer and have sat in on several Q & A with him.

The thing that he always says is the sooner the better with the epi pen.  He described symptoms being so unpredictable and can come down like an avalanche...once it is moving, very difficult to stop (meaning when the different systems start going into survival mode) and your chances of recovering are much higher if you are prompt with the epi pen.

So, if I "thought" my son was reacting, I would skip the benadryl and move right in with it because no harm will come from it, YK?

I did "almost" give him benadryl today because he said he was itchy all day and he had the hives on his arms from elbow down.  I was pretty sure it was an environmental thing.  He took a shower and was fine soon after. 

Also, my ds was switched to epi regular when he was 5 and initially the pharmacy wouldn't fill it.  He weighed around 50lbs

The allergist did all the math for me (I can't remember the calculation now) but the pharmacy did finally fll it.  I think it was as much his age as the weight that threw up the red flag.

[Macabre]

Burks' office has a lovely form that i would suggest you have them complete and send to you right away and not wait for your appointment. It's the allergy action plan that  will no doubt look somewhat familiar to you. Burks' has a column for symptoms and then two checkbox columns for epi and Benadryl. It's very clear explaining which symptoms you epi for and which you use the other.

Both DS and I have extreme sleepiness and lethargy as reaction symptoms. I thought your concern about using benadryl was solid and brilliant, frankly. However, I guess I would have used it initially in your circumstance if i put myself in that situation. But we are used to using it and would have done that right away. And if it progressed Epid.

DS was moved to an epi regular at 45 lbs.

[Macabre]

Okay--today I had a reaction. For shellfish, it affects my GI tract.  I was in a meeting. Ate something from a lunch place.  I had not taken my allegra this morning (out) but decided to take a Zantac once at work, as it's an H2 blocker (and btw--our allergist before we moved from TExas to Virginia told us to take it after anaphylaxis for a few days, as it works on different receptors). 

I first got spacey--that's what I do.  Then stomach cramps set in.  I went to CVS and bought some children's liquid benadryl. It didn't totally stop the reaction, but the second it hit my stomach, I felt better.  And this has worked for me for years (I've also had to epi for a reaction, btw).  But wow--that liquid benadryl feels sooooooooo wonderful on my stomach.

Now once DS had a reaction to some chips fried in peanut oil.  And after we gave him the Benadryl, he threw up, so I don't think it gave him benefit. But for my GI symptoms, it really feels better and works some.

BTW--my reaction has just about resolved i think  I took a second dose of benadryl about 45 minutes ago, and my small intestine is no longer hurting. 

Just posting this to give an idea of a time when it's helpful to use Benadryl.

[becca]

We were always told just epi, no benadryl.  But I have given dd benadryl for hives only contact reactions.

She was changed up to a reg epi at about 45 pounds.  There is a window between 45 and 60 or 65 if I recall, that neither covers?  I would have to look that up, but recalling that from an old discussion back when I switched dd up. 

[Mfamom]

Macabre, do you know what may have caused your rx today?

[lakeswimr]

Do you have a written emergency plan from Dr. Burks?  Does it call for Benadryl before epi ever or does it call for epi, then Benadryl? 

From what I have read from many others posting elsewhere about their emergency plans, allergists are about split on whether they wait for signs of a serious reaction and then have people give epi, followed by Benadryl or whether they tell people to give Benadryl for minor reactions and epi for more serious.  Our allergist calls for waiting to see if epi is needed and not giving Benadryl because he feels it can mask a more serious reaction.  The Benadryl also can not stop a reaction that is going to progress to life threatening from progressing so he feels there is no point to give it and a small risk of masking things.

FAAN published an article in which they stated that Benadryl won't mask a reaction that needs the epi or if it does there will still be enough time to give the epi. 

I think it is 6 of one, half dozen of the other as long as people give the epi for systemic reactions.  The trouble is that many people give Benadryl when they should give the epi, not that some give Benadryl for very minor reactions, in my opinion.

I would look at your written plan and follow it.  If you didn't receive a written plan from a doctor the likes of Burkes I'm very surprised. 

The nurse doesn't sound up to date and I would not be taking advice from her.  Benadryl doesn't stop reactions.  It is for minor  symptoms and for comfort.  It has no life saving capabilities.  most reactions will self resolve even without treatment so the fact that someone survives without the epi doesn't mean Benadryl stopped the reaction.  Also, Zyrtec is way slower than Benadryl and should not be given for anaphyalaxis.  give Benadryl if you are giving an antihistamine.  Also, I think kids normally move up on the epi at about 60 lbs but go up earlier if they have asthma.  If your child doesn't have asthma I would want to stick with the jr but YMMV.  I'd research that.  I agree, her answer would not make me feel reassured.

[lakeswimr]

Also, it has been a while since I talked about this with DS's allergist but he said something close to this... it can mask early symptoms and if we give Benadryl we might not see hives or an itchy mouth, etc continue outside the body.  Meanwhile, the reaction is continuing to spread silently inside the body and it is building strength but we think the opposite.  And then it comes out big and strong seemingly 'suddenly' and it can certainly have caused us to delay epi because of this.

[SilverLining]

The time I had my really serious reaction and was treated in the ER, I had not been carrying an epi.  I had taken benedryl as soon as the reaction started (first symptom was hives).  The hives cleared up, but then returned.  It was like a wave, crashing in, then fading away.  Symptoms progressed to anaphylaxis (though I didn't know it at the time). 

After spending a few hours in ER, getting epi and other stuff there, as I was leaving I said to the doctor that I guess the benedryl doesn't work for me any more.  She replied that it had kept me alive til I got there and helped slow the worst of the symptoms.

That's just one person's experience, and one ER doctor's opinion, but I thought it was worth adding into the conversation.

[twinturbo]

That's interesting about Sicherer relayed to you about epi, Mfamom. When we were
there we got the clear instruction that even with a history of respiratory symptoms from contact to ingestion, if we have a known ingestion (eat peanut) we benadryl first then wait for further reaction. I just yes'd them. I wouldn't wait around too much if he knowingly ate it. We can find out that it's not so bad once we're triaged with monitors and doctors.

[Janelle205]

I think that doctor's may be basing a lot of this on individual patient's experiences and history as well.  My doc still advises benadryl, even though I've had a contact ingestion reaction with respiratory involvement.  Luckily though, all of my anaphylactic reactions have been slow moving - I've had a good amount of time to decide to epi.  Things get just as bad for me, but luckily, I haven't had the scary fast, seconds to decide reactions that others have experienced.

To give this info with a grain of salt though, I will say that my doctor gives me personally a lot more latitude with my asthma treatment than he does with other patients as well, because he trusts me quite a bit, and frankly, if I followed the recs that some other doctors had given me regarding asthma, I'd be in and out of the ER once a week, minimum.