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Pharmacokinetics and renal excretion of diphenhydramine and its metabolites, diphenylmethoxyacetic acid and diphenhydramine-N-oxide, in developing lambs.

The developmental disposition of diphenhydramine (DPHM) and its metabolites, diphenylmethoxyacetic acid (DPMA) and DPHM-N-oxide (DPHMNO), was investigated in postnatal lambs. Lambs received a DPHM intravenous (iv) bolus 15 days (Group A; n = 5) or 2 months (Group B; n = 6) after birth. Total body clearance of DPHM in postnatal lambs (Group A = 138.7 +/- 80.5 mL/min/kg; Group B = 165.7 +/- 51.3 mL/min/kg) was similar to the nonplacental clearance values (i.e., the component of fetal total body clearance that is not due to elimination via the placenta) estimated for fetal lamb (116.3 +/- 49. 6 mL/min/kg), and significantly greater than estimates in adult sheep (38.5 +/- 12.3 mL/min/kg). In addition, Group A DPHM renal clearance (CL(r), >1.80 +/- 1.24 mL/min/kg) was similar to that of the fetus (2.06 +/- 0.24 mL/min/kg), and significantly greater than that for Group B (0.26 +/- 0.17 mL/min/kg) and the adult (0.012 +/- 0.005 mL/min/kg). In contrast, similar to the fetal situation, postnatal DPMA CL(r) (Group A = 0.02 +/- 0.02 mL/min/kg; Group B = 0.05 +/- 0.01 mL/min/kg) was significantly less than adult values (0. 53 +/- 0.19 mL/min/kg). Because DPMA is not sequentially metabolized in sheep, the lower CL(r) in postnatal lambs results in longer apparent elimination half-lives of this metabolite (Group A = 90.4 +/- 32.2 h; Group B = 13.13 +/- 11.0 h) compared with that in the adult (2.9 +/- 1.6 h). No age-related difference in DPHMNO CL(R) was observed. Alterations in the CL(r) of DPHM and DPMA are likely related to differences in the rate of development of mechanisms (i.e. , tubular secretion and reabsorption and glomerular filtration rate) involved in the urinary drug excretion of organic acids and bases.

Acetates↗

Simultaneous analysis of diphenhydramine and a stable isotope analog (2H10)diphenhydramine using capillary gas chromatography with mass selective detection in biological fluids from chronically instrumented pregnant ewes.

This report describes both the synthesis of a stable isotope analog of the H1 receptor antagonist diphenhydramine (DPHM), and the simultaneous quantitation of DPHM and a deuterated stable isotope analog of DPHM, viz. (2H10)DPHM in biological fluids from the chronically instrumented pregnant ewe. (2H10)DPHM was synthesized and purified, and both its structure and purity were verified. Biological samples were prepared for analysis using liquid-liquid extraction prior to capillary gas chromatography/mass spectrometry. The method employed electron impact ionization with selective ion monitoring of ions with m/z 165 for DPHM and m/z 173 for (2H10)DPHM. The minimal quantifiable concentration of DPHM and (2H10)DPHM from a 1.0 ml sample was 2.0 ng ml-1 in fetal and maternal plasma, fetal tracheal fluid and amniotic fluid. The method was validated from 2.0 ng ml-1 to 200.0 ng ml-1 for both DPHM and (2H10)DPHM in plasma, fetal tracheal fluid and amniotic fluid. Differences in the disposition between DPHM and (2H10)DPHM were not apparent during a control experiment in which both labeled and unlabeled DPHM were administered to a chronically instrumented fetal lamb. This method provides the required sensitivity and selectivity for the simultaneous quantitation of unlabeled and labeled DPHM during pharmacokinetic experiments conducted in near-term pregnant sheep.

Amniotic Fluid↗

Diphenhydramine toxicity: comparisons of postmortem findings in diphenhydramine-, cocaine-, and heroin-related deaths.

Diphenhydramine (DPH)-related deaths in adults are extremely rare, and detailed autopsy studies are rarer still. Toxicologic and anatomic findings in 4 cases of suicidal DPH overdose are described and compared with findings in a database of cocaine- and heroin-related deaths. Blood DPH levels were many times higher than those considered therapeutic (5000-35,000 ng/ml versus 50-100 ng/ml). Marked pulmonary edema with visceral congestion was a constant finding. Mean lung-body weight ratios for DPH, cocaine, heroin, and trauma controls were 0.015, 0.015, 0.019, and 0.013, respectively. When normalized for body weight in this fashion, edema in DPH-related deaths was comparable to that in cocaine-related deaths. Cardiac enlargement was apparent in 3 of the 4 DPH cases, 1 with marked myocardial fibrosis. The finding of increased heart size suggests that preexisting heart disease may provide the necessary substrate for lethal cases of DPH toxicity. Pulmonary edema in these cases remains unexplained, with edema in cases of heroin-related toxicity significantly worse than that produced by cocaine or DPH (p < .0001). Because DPH and cocaine can exert similar effects on the heart, a common mechanism may produce pulmonary edema in both. A different mechanism may account for heroin-related edema.

Adolescent↗

Validation of diphenhydramine as a dermal local anesthetic.

STUDY OBJECTIVE: Although diphenhydramine has been recommended as an alternate local anesthetic for patients claiming allergy to lidocaine, no prior placebo-controlled evaluations of diphenhydramine for dermal anesthesia have been performed. We sought to determine the relative efficacy of diphenhydramine compared to saline placebo and lidocaine. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING AND PARTICIPANTS: Twenty-four healthy adult volunteers. INTERVENTIONS: Subjects received intradermal 0.5-mL injections of diphenhydramine 1%, diphenhydramine 2%, lidocaine 1%, and normal saline placebo in a randomized, double-blind fashion. Extent of anesthesia (in mm2) was assessed at one, two, five, ten, 20, and 30 minutes. Pain of initial infiltration was assessed with a visual analog scale. MEASUREMENTS AND MAIN RESULTS: Diphenhydramine 1% produced greater anesthesia than placebo (P < .001) and equivalent anesthesia to lidocaine 1% (P = .889). (Our sample size had 90% power to detect a difference of 30% from the peak anesthesia observed.) Diphenhydramine 2% was less effective than diphenhydramine 1%; however, this difference was not statistically significant (P = .295). Infiltration of either concentration of diphenhydramine was significantly more painful than either lidocaine or saline (P < or = .001) for all comparisons). No clinically important complications were noted. CONCLUSION: In this study of 24 adult volunteers, diphenhydramine 1% was as effective as lidocaine 1% for achieving dermal local anesthesia, although injection was more painful. Although no clinically important complications were noted in our study, the safety of diphenhydramine remains to be established, especially in areas with poor collateral perfusion (eg, digits, pinna, and nose).

Adult↗

Clinical symptomatology of diphenhydramine overdose: an evaluation of 136 cases in 1982 to 1985.

In West Germany, the antihistaminic diphenhydramine is marketed as a non-prescription hypnotic. Results of toxicological screening in cases of drug overdose indicate that poisoning with diphenhydramine represents a substantial part (4.5%) of the total number of intoxications. A total of 136 cases of diphenhydramine poisoning in 1982-1985 were evaluated with respect to age, ingested dose, plasma level, and clinical symptomatology. All patients had taken diphenhydramine with suicidal intent. Two-thirds of the patients were aged 14-30 years. In about 50% of the cases, between 6 and 40 times a therapeutic dose was ingested. Diphenhydramine plasma levels showed a wide range (0.1-4.7/micrograms/ml) due to differences in ingested dose and time between ingestion and admission to hospital. Impaired consciousness was the most common symptom. Psychotic behavior similar to catatonic stupor--often combined with anxiety--was highly specific for diphenhydramine poisoning. Further symptoms included hallucinations, mydriasis, tachycardia, and less frequently diplopia, respiratory insufficiency, and seizures. Primary treatment included gastric lavage, administration of activated charcoal and sodium sulfate. In one case, hemodialysis and ultrafiltration were performed which had only limited effect on diphenhydramine plasma elimination kinetics. This patient died of diphenhydramine overdose and extreme hypothermia. All intoxications except the one mentioned before had an uncomplicated clinical course. In vitro experiments indicate that diphenhydramine may be almost completely removed from the plasma compartment by hemoperfusion. Routine analysis of urine samples in diphenhydramine overdose led to the identification of 4 previously unknown metabolites and artifacts of diphenhydramine.

Adolescent↗

Comparison of effects of lidocaine hydrochloride, buffered lidocaine, diphenhydramine, and normal saline after intradermal injection.

STUDY OBJECTIVE: To evaluate pain and the spread of analgesia when local anesthetics are given as an intradermal injection into the dorsal aspect of the hand. DESIGN: Randomized, double-blinded, placebo-controlled study. SETTING: University medical center. PATIENTS: 40 consenting adult volunteers. INTERVENTIONS: Volunteers were randomly assigned to receive a 0.25-mL injection of either lidocaine hydrochloride (1%), buffered lidocaine, diphenhydramine (1%), or placebo (0.9% sodium chloride solution) into the dorsal aspect of both hands. MEASUREMENTS: The volunteers used a visual analog scale to compare the pain of needle insertion and solution injection. Then at 1, 2, 5, 10, 20, and 30 minutes after intradermal injection, the extent of the analgesic area was marked on a strip of tape placed horizontally across the hand. Then at 32 minutes after intradermal injection, the extent of the analgesic area was marked on a strip of tape placed vertically across the hand. The volunteers were called each day and asked the duration of their numbness or hyperesthesia until their hands were no longer numb or sore. MAIN RESULTS: Buffered lidocaine during intradermal infiltration was found to be significantly (p < 0.05) less painful than either lidocaine hydrochloride or diphenhydramine and equivalent to placebo. Diphenhydramine and lidocaine hydrochloride during intradermal infiltration induced significantly (p < 0.05) more pain than buffered lidocaine or placebo. Lidocaine hydrochloride displayed a significantly (p < 0.05) larger diameter of analgesia than placebo by 1 minute after the injection, buffered lidocaine by 2 minutes after injection, and diphenhydramine by 5 minutes after injection. By 20 minutes after injection, diphenhydramine diameter of analgesia was significantly (p < 0.05) larger than placebo but significantly less than buffered lidocaine. By 30 minutes after injection, diphenhydramine diameter of analgesia was equivalent to placebo whereas buffered lidocaine and lidocaine diameters were still significantly (p < 0.05) larger than placebo. Diphenhydramine injection resulted in numbness that lasted significantly (p < 0.05) longer than other study solutions whereas buffered lidocaine and lidocaine injections resulted in numbness that lasted significantly longer than placebo. Diphenhydramine injection resulted in hyperesthesia that lasted for 2 or more days in 12 of the volunteers. CONCLUSION: There is a reduction of infiltration pain using buffered lidocaine as opposed to lidocaine and diphenhydramine. Although lidocaine injection resulted in a slightly faster spread of analgesic diameter, buffered lidocaine was equivalent to lidocaine from minute 2 until minute 30. Therefore, to obtain optimal anesthetic conditions, we recommend that buffered lidocaine be given 2 minutes before performing catheterization, whereas diphenhydramine should be given 5 minutes before catheterization, but only when buffered lidocaine cannot be used.

Adult↗

Transepithelial transport of diphenhydramine across monolayers of the human intestinal epithelial cell line Caco-2.

PURPOSE: The transepithelial transport characteristics of the antihistamine, diphenhydramine, were studied in human intestinal Caco-2 cell monolayers to elucidate the mechanisms of its intestinal absorption. METHODS: The transepithelial transport and the cellular accumulation of diphenhydramine were measured using Caco-2 cell monolayers grown in Transwell chambers. RESULTS: The transepithelial transport of diphenhydramine from the apical to basolateral side was saturable, and the flux and cellular accumulation of diphenhydramine were dependent on the apical extracellular pH (pH 7.4 > 6.5 > 5.5). Transport and accumulation of diphenhydramine from the apical side were inhibited by another antihistamine, chlorpheniramine, while typical substrates for the renal organic cation transport system such as tetraethylammonium, cimetidine and guanidine had no effect. The transepithelial transport and cellular accumulation of diphenhydramine from the basolateral side were also pH-dependent and inhibited by chlorpheniramine. In addition, intracellular diphenhydramine preloaded was preferentially effluxed to the apical side, suggesting the involvement of the secretory pathway in diphenhydramine transport. Furthermore, diphenhydramine uptake from both the apical and basolateral sides was stimulated by preloading monolayers with chlorpheniramine (trans-stimulation effect). CONCLUSIONS: Transepithelial transport of diphenhydramine across Caco-2 cells is mediated by pH-dependent, specific transport systems that exist in both the apical and basolateral membranes.

Algorithms↗

Infiltration pain and local anesthetic effects of buffered vs plain 1% diphenhydramine.

OBJECTIVE: To compare the levels of infiltration pain and local anesthetic effects of plain and buffered 1% diphenhydramine. METHODS: A prospective, randomized, double-blind, paired study was performed using 30 adult volunteers. Intradermal injections (0.5 mL) of plain and buffered 1% diphenhydramine were made in the subjects' forearms, one in the left and the other in the right. The pain of infiltration was recorded on a previously validated 10-cm visual analog scale (VAS). The volunteers also were asked which injection was less painful. Sequential measurements of the diameter of anesthesia to pinprick were made at 1, 2, 5, 10, 15, 20, 25, and 30 minutes. The VAS scores and anesthetic diameters were compared for plain and buffered diphenhydramine using a paired Wilcoxon rank sum test. RESULTS: There was no statistically significant difference between buffered diphenhydramine and plain diphenhydramine for pain of injection (23.5 +/- 19.2 mm vs 28.2 +/- 18.7 mm, p = 0.24). Repeated-measures analysis of variance for anesthetic diameters demonstrated no significant difference between buffered diphenhydramine and plain diphenhydramine (p = 0.87). At no single measurement period were the anesthetic diameters different. CONCLUSIONS: In a study with a sample size large enough to detect an 11-mm difference in VAS scores (power = 80%), no difference was found in pain of infiltration and anesthetic effects when plain 1% diphenhydramine was compared with buffered 1% diphenhydramine. Buffering of diphenhydramine does not appear to result in a clinically significant reduction in the pain of infiltration.

Adult↗

NTP Toxicology and Carcinogenesis Studies of Diphenhydramine Hydrochloride (CAS No. 147-24-0) in F344/N Rats and B6C3F1 Mice (Feed Studies).

Diphenhydramine hydrochloride is a widely used antihistaminic drug in human and veterinary medicine. Toxicology and carcinogenesis studies were conducted by feeding diets containing USP-grade diphenhydramine hydrochloride (greater than 99% pure) to groups of F344/N rats and B6C3F1 mice of each sex for 14 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, mouse L5178Y cells, and Chinese hamster ovary (CHO) cells. Fourteen-Day and Thirteen-Week Studies: In the 14-day studies, dietary concentrations ranged from 620 to 10,000 ppm for rats and from 310 to 5,000 ppm for mice. All rats that received diets containing 10,000 ppm and 9/10 rats that received diets containing 5,000 ppm died before the end of the studies. The final mean body weights of rats receiving 1,250 or 2,500 ppm were 12%-13% or 30%-34% lower than those of controls. Feed consumption by rats at the three highest concentrations was more than 30% less than that by controls. All mice receiving 5,000 ppm, 4/5 males and 4/5 females receiving 2,500 ppm, and 4/5 males receiving 1,250 ppm died before the end of the studies. The final mean body weights of mice that received 1,250 or 2,500 ppm were lower than the initial weights. All dosed rats and mice were hyperactive and sensitive to sound and/or touch. In the 13-week studies, dietary concentrations of diphenhydramine hydrochloride ranged from 156 to 2,500 ppm for rats and from 78 to 1,250 ppm for mice. All rats lived to the end of the studies. The final mean body weights of rats receiving 1,250 or 2,500 ppm were about 15% or 35% lower than those of controls. The final mean body weight of female rats receiving 625 ppm was 9% lower than that of controls. Increased activity was observed for all male and female rats receiving 1,250 and 2,500 ppm. Cytoplasmic vacuolization of the liver, characteristic of fat accumulation, was observed in male and female rats receiving 313-2,500 ppm. The severity of this change increased with increased dose. For mice, 1/10 males receiving 313 ppm, 2/10 males receiving 625 ppm, and 8/10 males receiving 1,250 ppm died before the end of the studies. The final mean body weights of mice that received 625 or 1,250 ppm were about 9% or 16% lower than those of controls. No compound-related histopathological effects were observed in mice. Based on the mortality and body weight effects of diphenhydramine hydrochloride in the short-term studies, dietary concentrations selected for the 2-year studies were 0,313, and 635 ppm diphenhydramine hydrochloride for male rats and 0, 156, and 313 ppm for female rats and male and female mice. Body Weight and Survival in the Two-Year Studies: Mean body weights of dosed and control rats were similar throughout the studies, and mean body weights of dosed mice were 3%-13% lower than those of controls throughout most of the studies. No significant differences in survival were observed between any groups of rats or mice of either sex (male rats: control, 29/50; low dose, 32/50; high dose, 24/50; female rats: 35/50; 32/50; 36/50; male mice: 29/50; 30/50; 24/48; female mice: 37/50; 39/50; 32/50). The estimated average daily feed consumption by dosed rats and dosed mice was similar to that by controls. The average amount of diphenhydramine hydrochloride consumed per day was approximately 13 or 27 mg/kg for low dose or high dose male rats, 7 or 15 mg/kg for low dose or high dose female rats, and 21 or 46-47 mg/kg for low dose or high dose male and female mice. Nonneoplastic and Neoplastic Effects in the Two-Year Studies: For three high dose male rats, astrocytomas were found in brain sections taken by routine sampling procedures. Gliomas, containing neoplastic astrocytes and oligodendrocytes, were found in one control and one additional high dose male rat. The incidence of glial cell tumors in high dose male rats (4/50) exceeded the highest incidence in historical controls in the Program (2/50). The historical incidence of glial cell tumors is less than 0.7% in approximately 2,000 untreated control male F344/N rats. Three addiless than 0.7&percnt; in approximately 2,000 untreated control male F344/N rats. Three additional sections of brain were prepared from the residual fixed tissues of each male and female rat. One additional astrocytoma in a high dose male rat and one astrocytoma in a high dose female rat were observed in these sections. Adenomas of the anterior pituitary gland in female rats occurred with a significant positive trend; the incidences in low dose male and high dose female rats were marginally greater than those in controls (male: control, 11/49; low dose, 21/50; high dose, 14/49; female: 23/50; 26/50; 35/50). The incidence of alveolar/bronchiolar adenomas in low dose male rats was slightly greater than that in controls (0/49; 5/50; 3/50). The incidences of alveolar/bronchiolar adenomas or carcinomas (combined) in dosed male rats were not significantly different from that in controls (1/49; 6/50; 5/50) but exceeded the highest incidence in historicalcontrols (4/49). The historical incidence of alveolar/bronchiolar neoplasms in untreated control male F344/N rats is approximately 2.2&percnt;. Adenomatous hyperplasia of the lung was not increased in incidence in dosed male rats compared with controls. The incidences of granulomas of the liver were increased in dosed rats (male: 0/49; 3/50; 4/50; female: 8/50; 15/49; 18/50). At no site were the incidences of neoplastic lesions in dosed mice considered to be compound related. Cytoplasmic vacuolization (fatty metamorphosis) of the liver was observed at an increased incidence in high dose female mice (0/49; 1/49; 8/49). Genetic Toxicology: Diphenhydramine hydrochloride was not mutagenic in S. typhimurium strains TA98, TA100, TA1535, or TA1537 when tested in either the presence or absence of exogenous metabolic activation. Exposure to this chemical did not induce trifluorothymidine (Tft) resistance in mouse L5178Y lymphoma cells with or without metabolic activation. In cytogenetic tests with cultured CHO cells, diphenhydramine hydrochloride induced chromosomal aberrations in the absence, but not the presence, of exogenous metabolic activation (S9); no induction of sister chromatid exchanges (SCEs) was observed in these cells with or without S9. Conclusions: Under the conditions of these 2-year feed studies, there was equivocal evidence of carcinogenic activity of diphenhydramine hydrochloride for male F344/N rats, based on marginally increased incidences of uncommon brain neoplasms (astrocytomas or gliomas) and of alveolar/bronchiolar neoplasms. There was equivocal evidence of carcinogenic activity for female F344/N rats, based on a marginal increase in the incidence of pituitary gland adenomas. There was no evidence of carcinogenic activity for male or female B6C3F1 mice fed diets containing 156 or 313 ppm diphenhydramine hydrochloride. Synonyms: 2-diphenylmethoxy-N,N-dimethylethanamine hydrochloride; 2-(benzhydryloxy)-N,N-dimethylethylamine hydrochloride; b-dimethylaminoethyl benzhydryl ether hydrochloride; benzhydramine hydrochloride Trade Names: Alleran; Benadryl

Journal Article↗

Effects of H1 antagonists on cholinomimetic-induced tremulous jaw movements: studies of diphenhydramine, doxepin, and mepyramine.

In several previous studies, tremulous jaw movements in rats have been used to assess the effects of antiparkinsonian drugs and atypical antipsychotics. Because antihistamines such as diphenhydramine are used as antiparkinsonian agents, and atypical antipsychotic drugs such as clozapine and olanzapine have high affinity for histamine H1 receptors, the present study investigated the effects of H1 antagonists on cholinomimetic-induced jaw movements. Diphenhydramine, doxepin, and mepyramine (all injected IP 2.5-20.0 mg/kg) were assessed for their ability to block the jaw movements induced by 5.0 mg/kg of the anticholinesterase tacrine. Within this dose range, only diphenhydramine produced a robust and significant reduction in jaw movement activity. Thus, diphenhydramine was subjected to further testing, which employed procedures previously used to assess the effects of other antitremorogenic drugs, such as clozapine. Diphenhydramine did not induce jaw movement activity. In addition to suppressing jaw movement activity after acute injections, diphenhydramine also suppressed tacrine-induced jaw movements after repeated (14-day) administration. In summary, the present results show that diphenhydramine suppresses cholinomimetic-induced jaw movements, an effect that is similar to other antiparkinsonian or antitremor drugs such as anticholinergics, L-DOPA, DA antagonists, and clozapine. Nevertheless, doxepin produced only mild effects, and mepyramine, which has a higher affinity and selectivity than diphenhydramine for H1 receptors, failed to suppress cholinomimetic-induced jaw movements. These results suggest that diphenhydramine suppresses tremulous movements through a mechanism that does not depend upon antagonism of histamine H1 receptors.

Animals↗

The effects of diphenhydramine and SR142948A on periaqueductal gray neurons and on the interactions between the medial preoptic nucleus and the periaqueductal gray.

The midbrain periaqueductal gray contains both neurotensin type-1 and type-2 receptors. Behavioral studies have shown that the analgesic effect of neurotensin is mediated through its interaction with the type-2 receptors. These receptors specifically bind the type-1 histamine antagonist, levocabastine. Recently, it has been shown that another histamine-1 antagonist, diphenhydramine, blocks the analgesic effect of neurotensin. In addition, it has been shown that a non-peptide neurotensin antagonist, SR142948A, binds to both types of neurotensin receptors and blocks the analgesic effect of exogenously applied neurotensin. Major afferents to the periaqueductal gray arise from the medial preoptic nucleus of the hypothalamus. This region contains neurotensinergic neurons, and the expression of neurotensin mRNA in this region increases following cold-water swim stress that leads to opioid-independent analgesia. The goal of this study was to determine whether the responses of periaqueductal gray neurons to stimulation of the medial preoptic nucleus are modified by local injection of diphenhydramine and SR142948A. Because the cellular basis of the effects of diphenhydramine on periaqueductal gray neurons had not been reported, we also examined the effects of diphenhydramine on the baseline-firing rate and synaptic transmission using in vivo and in vitro methods. The results of the in vitro studies indicate that diphenhydramine concentrations above 500 nM significantly reduce the baseline firing of the periaqueductal gray neurons without a significant effect on the frequency of postsynaptic potentials. At concentrations below 100 nM, diphenhydramine has little effect on the baseline-firing rate but partially blocks the response to neurotensin. The results of the in vivo studies showed similar effects of diphenhydramine. At high concentrations it inhibited periaqueductal gray neurons, but at low concentrations it had no effect on the baseline-firing rate and it blocked the response to neurotensin and to medial preoptic nucleus stimulation. Unlike diphenhydramine, SR142948A had virtually no effect on the baseline-firing rate but blocked the response to neurotensin and to stimulation of the medial preoptic nucleus. It is concluded that: (1) SR142948A, at a dose that completely blocks the effect of exogenously applied neurotensin on periaqueductal gray neurons, has little effect on their baseline-firing rates. (2) Because of its effect on the baseline-firing rate, only low doses of diphenhydramine can be used as an antagonist of the neurotensin analgesic effect. (3) Responses of periaqueductal gray neurons to medial preoptic nucleus stimulation is, in part, mediated by a neurotensinergic network within the periaqueductal gray.

Adamantane↗

Increased risk of serious injury following an initial prescription for diphenhydramine.

BACKGROUND: Diphenhydramine may be associated with excess risk of injury relative to nonsedating H1-receptor antagonists. OBJECTIVE: This study sought to compare the risk of injury in patients exposed to diphenhydramine with the risk of injury in patients exposed to loratadine. METHODS: A retrospective cohort study of injury was carried out in 12,106 patients whose initial antihistamine prescription was for diphenhydramine and in 24,968 patients whose initial antihistamine prescription was for loratadine. Data were taken from a health care claims database that included employees, dependents, and retirees who filed claims from January 1991 through December 1998. Rates of six serious injuries in the diphenhydramine cohort after and before the first prescription were compared with rates in the loratadine cohort after and before the first prescription. RESULTS: In the 30 days after the first antihistamine prescription, the rate of all injuries was 308 per 1,000 person-years in the diphenhydramine cohort versus 137 per 1,000 person-years in the loratadine cohort. The rate ratio estimate adjusted for age and gender using Poisson regression was 2.27 (95% confidence limits [CL] 1.93, 2.66). In the corresponding 30 days of the preceding year, the injury rates in the diphenhydramine and loratadine cohorts were 128 and 125 per 1,000 person-years, and the adjusted rate ratio was 1.02 (CL 0.83, 1.26). Thus, the cohorts appeared to have similar preprescription injury rates. The differences between the cohorts declined with time from prescription: For all injuries, the estimated percentage decline in the rate ratio was 4.1% per day (CL 3.3, 4.9), and the estimated time from the initial prescription until the diphenhydramine cohort returned to baseline risk was 32.3 days (CL 26.9, 37.6). CONCLUSIONS: If these associations are causal, the percentage of the injuries attributable to diphenhydramine was 55% (CL 41, 65), implying a substantial number of excess injuries and costs incurred as the result of diphenhydramine use. The high use rates of this drug and the high incidence of injury suggest that further study of the association between injury and type of antihistamine is needed.

Adolescent↗

Significant interaction between the nonprescription antihistamine diphenhydramine and the CYP2D6 substrate metoprolol in healthy men with high or low CYP2D6 activity.

The prototype "classic" over-the-counter antihistamine diphenhydramine was shown to interact with the polymorphic P450 enzyme CYP2D6. This project was undertaken to investigate (1) whether diphenhydramine inhibits the biotransformation of the clinically relevant CYP2D6 substrate metoprolol in vitro and (2) whether this in vitro interaction results in a clinically significant pharmacokinetic and pharmacodynamic drug interaction in vivo. In vitro incubations were carried out with microsomes obtained from lymphoblastic cells transfected with CYP2D6 complementary deoxyribonucleic acid to determine the type and extent of inhibition. We then randomized 16 subjects with genetically determined high (extensive metabolizers) or low (poor metabolizers) CYP2D6 activity to receive metoprolol (100 mg) in the presence of steady-state concentrations of diphenhydramine or placebo. In vitro, diphenhydramine was a potent competitive inhibitor of metoprolol alpha-hydroxylation, exhibiting an inhibitory constant of 2 micromol/L and increasing the Michaelis-Menten constant of metoprolol sixfold. In vivo, diphenhydramine decreased metoprolol oral and nonrenal clearances twofold and metoprolol-->alpha-hydroxymetoprolol partial metabolic clearance 2.5-fold in extensive metabolizers (all P < .05) but not in poor metabolizers (P > .2). Although the hemodynamic response to metoprolol was unaltered by diphenhydramine in poor metabolizers (P > .05), metoprolol-related effects on heart rate, systolic blood pressure, and Doppler-derived aortic blood flow peak velocity were more pronounced and lasted significantly longer in extensive metabolizers receiving diphenhydramine compared with poor metabolizers and extensive metabolizers receiving placebo. We conclude that diphenhydramine inhibits the metabolism of metoprolol in extensive metabolizers, thereby prolonging the negative chronotropic and inotropic effects of the drug. Clinically relevant drug interactions may occur between diphenhydramine and many CYP2D6 substrates, particularly those with a narrow therapeutic index.

Adrenergic beta-Antagonists↗

Diphenhydramine alters the disposition of venlafaxine through inhibition of CYP2D6 activity in humans.

CYP2D6 is the major enzyme involved in the metabolism of venlafaxine. Subjects with a low CYP2D6 activity have increased plasma concentrations of venlafaxine that may predispose them to cardiovascular side effects. In vitro and in vivo studies showed that diphenhydramine, a nonprescription antihistamine, can inhibit CYP2D6 activity. Therefore, the authors investigated in this study a potential drug interaction between diphenhydramine and venlafaxine. Fifteen male volunteers, nine with the extensive metabolizer (EM) and six with the poor metabolizer (PM) phenotype of CYP2D6, received venlafaxine hydrochloride 18.75 mg orally every 12 hours for 48 hours on two occasions (1 week apart): once alone and once during the concomitant administration of diphenhydramine hydrochloride (50 mg every 12 hours). Blood and urine samples were collected for 12 hours under steady-state conditions. In EMs, diphenhydramine decreased venlafaxine oral clearance from 104+/-60 L/hr to 43+/-23 L/hr (mean +/- SD; p < 0.05) without any effect on renal clearance (4+/-1 L/hr during venlafaxine alone and 4+/-2 L/hr during venlafaxine plus diphenhydramine). In PMs, coadministration of diphenhydramine did not cause significant changes in oral clearance and partial metabolic clearances of venlafaxine to its various metabolites. Diphenhydramine disposition was only slightly affected by genetically determined low CYP2D6 activity or concomitant administration of venlafaxine. In conclusion, diphenhydramine, at therapeutic doses, inhibits CYP2D6-mediated metabolism of venlafaxine in humans. Clinically significant interactions could be encountered during the concomitant administration of diphenhydramine and other antidepressant or antipsychotic drugs that are substrates of CYP2D6.

Adult↗

Diphenhydramine transport by pH-dependent tertiary amine transport system in Caco-2 cells.

Substrate specificity and pH dependence of the transport system for diphenhydramine were investigated in Caco-2 cell monolayers. Diphenhydramine uptake was not affected by any typical substrate for the renal organic cation transport system except procainamide. Along with procainamide, tertiary amine compounds with N-dimethyl or N-diethyl moieties in their structures inhibited the diphenhydramine uptake. Moreover, accumulation of diphenhydramine was stimulated by preloading the Caco-2 cells with these tertiary amines (trans-stimulation effect), indicating the existence of the specific transport system for tertiary amines with N-dimethyl or N-diethyl moieties. Efflux of diphenhydramine from monolayers was enhanced by medium acidification. In addition, intracellular acidification resulted in marked stimulation of diphenhydramine accumulation. ATP depletion of the cells caused an enhancement of diphenhydramine accumulation, suggesting the involvement of an active secretory pathway. However, P-glycoprotein did not mediate the diphenhydramine transport. These findings indicate that a novel pH-dependent tertiary amine transport system that recognizes N-dimethyl or N-diethyl moieties is involved in diphenhydramine transport in Caco-2 cells.

ATP Binding Cassette Transporter, Subfamily B, Mem↗

Lidocaine versus diphenhydramine for anesthesia in the repair of minor lacerations.

This prospective study compared the effectiveness of 1% diphenhydramine with 1% lidocaine for local anesthesia in repair of minor skin lacerations in adults with simple linear lacerations treated at our Emergency Department. Wounds were anesthetized with either lidocaine or diphenhydramine according to a random numbers table. Ninety-nine patients were included in the final analysis (51 received lidocaine; 48 diphenhydramine). Patients and physicians rated the pain of injection and suturing using a standard visual analog scale. Univariate and multivariate linear models were used on rank transformed scores of the patient and physician ratings of injection and suturing with p < 0.05 considered statistically significant. According to patient rating lidocaine was less painful for injection than diphenhydramine, with a statistically significant difference between the two anesthetics (p = 0.0017). There was no statistically significant difference in pain rating by physicians between the two anesthetics (p > 0.05). Pain with suturing was rated as minimal for both lidocaine and diphenhydramine with no statistically significant difference in the effectiveness according to either patients or physicians (p > 0.05). Lidocaine injection appears to hurt less than diphenhydramine injection according to the patients. Pain of suturing corresponding to anesthetic effectiveness appears to be equivalent for lidocaine and diphenhydramine according to both physicians and patients. Although diphenhydramine should not be substituted for lidocaine, it appears to be a viable alternative in the management of patients with allergy to amides or extremely large lacerations in which a maximum of amide anesthetic has been used.

Adolescent↗

Transport characteristics of diphenhydramine in human intestinal epithelial Caco-2 cells: contribution of pH-dependent transport system.

Transport characteristics of diphenhydramine, an antihistamine, were studied in cultured human intestinal Caco-2 cell monolayers to elucidate the mechanisms of its intestinal absorption. Diphenhydramine accumulation in the monolayers increased rapidly and was influenced by extracellular pH (pH 7.4 > 6.5 > 5.5). Diphenhydramine uptake was temperature dependent, saturable, and not potential sensitive. Kinetic analysis revealed that the apparent Km values were constant (0.8-1.0 mM) in all pH conditions tested, whereas Vmax values decreased at the lower pH. The initial uptake of diphenhydramine was competitively inhibited by another antihistamine, chlorpheniramine, with a Ki value of 1.3 mM. On the other hand, cimetidine and tetraethylammonium, typical substrates for the renal organic cation transport system, had no effect. Moreover, biological amines and neurotransmitters, such as histamine, dopamine, serotonin, and choline, also had no effect on the diphenhydramine accumulation. Finally, diphenhydramine uptake was stimulated by preloading monolayers with chlorpheniramine (trans-stimulation effect). These findings indicate that diphenhydramine transport in Caco-2 cells is mediated by a specific transport system. This pH-dependent transport system may contribute to the intestinal absorption of diphenhydramine.

Biological Transport, Active↗

Antitussive effects of diphenhydramine on the citric acid aerosol-induced cough response in humans.

This controlled crossover study in twenty healthy volunteer subjects utilized the citric acid aerosol-induced cough response as a means to demonstrate the effectiveness of 25 mg of diphenhydramine as an antitussive. Entry was limited to only those subjects who manifested a consistent, quantitatively definable response to a 5% citric acid challenge. Subjects were initially dosed with either a placebo vehicle or 25 mg diphenhydramine in a 10 ml formulation. Following drug ingestion, subjects were challenged at 15, 30, 45, 60, 120, and 240 minutes. Three days later, subjects were administered the alternate treatment and rechallenged at the same time points. Diphenhydramine was effective at the earliest time point assessed, 15 minutes, and continued to be as effective over the entire 4-hour duration of the test period. For the placebo vehicle, the mean cough counts did not change significantly from baseline. Neither the putative soothing effect of a liquid formulation nor accommodation to the citric acid spray can account for all the early and consistently significant activity of diphenhydramine in suppressing the cough response. The early onset of activity of diphenhydramine may be due to its local anesthetic properties or may indicate that the dose of diphenhydramine required for effective antitussive activity is lower than that required for effective antihistaminic activity. These results require further corroboration in direct comparisons of various doses of diphenhydramine with positive controls in both this model and clinical cough counting models employing pathologic cough indices. A 25 mg dose of diphenhydramine appears to be effective as an antitussive agent.

Administration, Inhalation↗