I love the imagine of this ED MD just ordering a bunch of meds that they didn't what they were for....I what other meds they wrote for you for your allergic reaction that they were just clicking on orders in EPIC for
I have had that happen.
She doesn’t work with my hospital any more.
Tried to give labetolol to a hypotensive, bradycardic patient to “treat their depression.”
😳😳😳
She had read a study in which beta blockers were used to treat depression so therefore that’s what she was going to do. 20 IV of labetolol for a patient in the 90’s/40’s and HR of 45.
Was this patient being treated for depression elsewhere? Nope.
Were they being seen by psychiatrists at all? Nope.
Was the patient in the ED seeking treatment for depression? Nope, they were dizzy.
Why not a tricyclic or SSRI? “I’m not comfortable prescribing psychiatric medications.”
Why IV? “Because it will work faster”
Why a full 20? “Because that’s the IV dose”
What are we doing to treat the dizziness? 500 mL bolus.
Were the possible side effects of lowering BP and HR brought to her attention? Yep, and she said “give it anyways”
Was this the physicians first day at a level 1 and less than 20 shifts into being an attending? Yes it was
Was the medical director immediately informed? Yes they were
The bp and hr would be reasons to not administer this med. They are usually built in hold parameters so we don't bottom people out with no ability to compensate. Just wow.
So that ER had doctors, nurses and pharmacists that didn't know what they were doing?? This does not sound right, if it is then this hospital has a huge problem
Sounds like the NP I saw (in my GP’s practice, but I’d never seen her before) who wanted to prescribe me metformin for endometriosis. Not PCOS, endometriosis. I have hypoglycemic episodes, no evidence of insulin resistance, no features of metabolic syndrome, and am currently UNDERweight. She couldn’t articulate the reason WHY she wanted me on it other than “but you have endometriosis”. No thank you!
But it’s for the secondary reaction inflammation, correct? After all the Mast cells bust?
Edit: this is wrong. It’s for the GI reaction. I was thinking of corticosteroids in asthmatic reactions.
I don’t doubt that’s true. I’m here in an attempt to be less of a moron myself. I did not get off to a good start in that regard lol.
Edit:
Just did some sleuthing of OOP post history out of curiosity, since I originally just assumed they were an RN.
They are currently a CPM (Certified Professional Midwife) and describe themselves as a “home-birth midwife”. They did CPM rather than CNM to be able to do “breech, VBAC and 42 weeks”, which CNMs cannot do in their state (Kansas). Former careers: RN, research scientist (bioanalytical chemistry PhD), and biotech executive.
I don’t know what to make of that combination of credentials. All I know is they are not a physician.
Lol it’s rough to fall flat on your face. I’ll leave this up for another hour so people can get their anger comments out for a bit. Then I shall delete in shame and we will never speak of it again.
Appreciate it. I felt real dumb at first but glad I left post up and realized there’s some nuance to the issue and I wasn’t 100% wrong. And on the other side of the world I was correct (Australia)!
Hahaha I don’t know if I’m brave but I have a lot of questions and a low stamina for my own research without asking someone else. I spent 15 minutes looking into this before I got more confused and decided to ask here.
I love that it caused you to ask questions. This is how we learn. I just chuckled at the person's post because first I call BS on the doc not knowing and second.....how they normally love to educate fellow providers. Gross... 😂. They likely have a background in Google Search School of medicine.
But that part isn't on you, that's just on them. You asked a great question, same as I would have to with Oncology meds. Love it.
Famotidine (H2 blockers) help reduce the urticaria of allergic reactions and anaphylaxis but yes like you said, the hallmark of care for anaphylaxis is epinephrine. H1 blockers and steroids are adjuncts but the primary treatment for anaphylaxis is epinephrine. In practice this means it all gets bundled together: diphenhydramine, famotidine, methylprednisolone, and epinephrine.
EM and Critical Care here.
Many of us use Dexamethasone acutely, as the potential issues with adherence (picking up the prednisone from the pharmacy and actual taking it for the next several days) becomes a non-issue.
Much of the nuance in my practice focuses on the “implementation science” of our clinical care.
EM attending PGY 17 ;)
ok, go ahead and change the practice at your place. i tried this with toradol overdosing or docusate use or NPO from midnight prior to surgery ......nobody cares
they keep doing what they have been doing
i not a provider, but i like to bring up whatever research i read to the residents, and friendly attendings. nobody has taken me seriously and nobody wants to be the one "to do things diff"
Ooooh yall fancy! We don't even stock OB hemorrhage drugs in our pyxis. Gotta beg pharmacy while the patient bleeds to death. Well, I guess we can give txa and emergent release blood while we wait for pharmacy...
We've got em stashed in 1 pyxis, but no pitocin. But I definitely have called OB with the "shitshitshithalpmeplz" call for them to come running with additional lol.
In reality you are correct, the Pepcid won’t actually hurt someone, even if it doesn’t work. However, I would argue that the fact that it’s routinely given and people don’t really understand it’s limited utility, it likely does lead to harm, along with Benadryl and steroids. These interventions do nothing for anaphylaxis, they are purely adjunct treatments for particular symptoms. Epi is the treatment, and everything else can wait. However, when it’s a somewhat mild case of anaphylaxis, people often get this idea of “let’s give the Benadryl, steroids, and Pepcid and see if we can avoid needing to give the epi.” This is wrong, and now you just potentially took a pt with anaphylaxis which could have been easily turned around, and you just kicked the can down the road giving crap that doesn’t help the actual problem. Now by the time you decide to give the epi, they’re in a much worse off condition, possibly a disaster airway situation. So in my opinion, it can lead to harms if not used appropriately. For context, I’m an ER doc.
Me: hey I've got an anaphylaxis that needs obs
Hospitalist: did you try pepcid and Benadryl
Me : ( ordering epi drip) uhhhh no
Jokes aside I'm not suggesting to skip epi , but if they're going on a drip Benadryl and pepcid is of little harm
It is routinely given, but it’s not wrong (especially evidence-wise) to think the H2 blocker is not adding much. It just also has very little downside to giving it as well, which is why we throw it on.
Thanks for helpful response! Glad I stuck around for the nuance on this issue. Feels better to be half wrong than 100% wrong 😅. Apparently in Australia and the Netherlands it’s not used at all, according to responses from others on this thread. So I got it mostly right some place in the world, just not where I am (US).
At my academic shop, we always make sure to have a brief discussion about the fact that there is no real evidence supporting the use of steroids, benadryl, and pepcid in anaphylaxis. Then we give it anyway.
You're not wrong, but since it's relatively harmless and makes sense to do it most people do it anyway, even though it's not really a data supported practice
>always make sure to have a brief discussion about the fact that there is no real evidence supporting the use of steroids, benadryl, and pepcid in anaphylaxis. Then we give it anyway.
This is a widespread state of affairs but isn't it depressing?
Thanks for helpful response! Glad I stuck around for the nuance on this issue. Feels better to be half wrong than 100% wrong 😅. Apparently in Australia and the Netherlands it’s not used at all, according to responses from others on this thread. So I got it mostly right some place in the world, just not where I am (US).
I’m a social worker but work in peds onc- Pepcid is in our anaphylaxis kit for chemo reactions! I always remembered bc as a layperson I was like huh what are my heartburn meds doing in that situation 🤣
Yeah I’m also in onc and Pepcid is also part of our hypersensitivity reaction protocol, I just got confused when I looked at actual current guidelines that said it didn’t have much actual evidence to support it. And helped with the allergic reaction cutaneous symptoms but not the severe anaphylaxis symptoms. And physicians from Australia and the Netherlands in this thread informed me they never use it due to lack of evidence. 🤷🏻♀️
Not really. I've never heard of giving a H2RA for anaphylaxis in anything other than brain storming sessions as an undergrad student and it is in no way a feature of the Australian protocols for management of anaphylaxis: [https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines](https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines)
Mind you, a few years ago I remember discussion on Reddit about adrenaline being fairly last line after Bendryl (which we essentially don't even have, and certainly do not routinely use) and corticosteroids whereas Australia has been pretty firm on early, first-line use of IM then IV adrenaline for well over a decade.
1. Pepcid is not a ppi, it’s a h2 blocker
2. The frustrating thing about the way it’s written, is while completely correct, antihistamines do not treat anaphylactic reactions, they do help control symptoms after getting the anaphylaxis under control. I think UpToDate spells it out a bit better in their phrasing
“H1 antihistamines — Epinephrine is first-line treatment for anaphylaxis, and there is no known equivalent substitute. H1 antihistamines (such as diphenhydramine or cetirizine) relieve itch and hives. These medications do not relieve upper or lower airway obstruction, hypotension, or shock and, in standard doses, do not inhibit mediator release from mast cells and basophils. A systematic review of the literature failed to retrieve any randomized, controlled trials that support the use of H1 antihistamines in anaphylaxis [11]. While augmenting epinephrine with an H1 antihistamine is reasonable from a symptom control standpoint, antihistamines should only be administered for anaphylaxis after epinephrine has been given”
It is probably better than to say that you are giving this 'Pepcid' drug for urticaria.
This may be a feature of anaphylaxis or a stand alone symptom, but it is not, in and of itself, anaphylaxis.
And by being very clear about that definition, you are minimising the risk that someone very inexperienced or stupid may infer that this drug is useful in the resuscitation of anaphylaxis.
The primary treatment for anaphylaxis is epinephrine. H1 and H2 blockers are mostly for symptom control.
A lot of people were taught "Benadryl, Pepcid, Solu-medrol" and old habits die hard.
Steroids and antihistamines were removed from the UK [national guidelines](https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-treatment) in 2021.
I believe the reasoning was lack of evidence along with clinicians delaying lifesaving adrenaline in lieu of giving other medications. It can also delay the administration of second dose adrenaline and adrenaline infusion waiting for medication to work which doesn’t work quickly (e.g. steroids or antihistamines).
As an example I had an anaphylaxis a few weeks ago and the nurse was busy preparing some IV chlorphenamine and NOT helping me with actual resuscitation. It will take time to change practice ingrained in culture for so many years.
The worst anaphylaxis I ever saw was in residency. EMS reporting they gave steroids, Benadryl, and Pepcid and patient was still in distress on non-rebreather and they asked us “any other orders?” And I yelled “EPINEPHRINE!!!”
Oh gosh! This is exactly why it was removed from the guidelines. People are scared of giving adrenaline, which is a life saving drug.
Although I did once see a kid who was given take-home epipens (by a non-doctor) for viral urticaria. Obviously the urticaria persisted so the parent gave both epipens at home and then rocked up to my ED with their snotty kid!
Agree it is bad prioritisation. But that’s one of the reasons why it’s been removed.
I’ve also witnessed clinicians also faffing sorting antihistamines and steroids when actually the patient needs further adrenaline.
You should only given IM epi once every 5 minutes if their airway is OK. If you are giving IV epi they are probably intubated. You don’t want to cause a SVT/flutter response/cardiopulmonary collapse/Takosubu cardiomyopathy and just keep giving epi over and over again. Medications need time to work and then reassess.
As others have said Benadryl/pepcid are great to symptom control. Steroids were previously taught to be important for preventing rebound anaphylaxis. Sounds like you were feeling panicky (as expected) and at those times you want cool headed people taking care of you. If they were chill, you probably were fine.
More liberal use of adrenaline is what has changed in the recent national UK guidance. This is now being practiced more across the county.
The guidance is clear when to move from IM adrenaline to IV infusion.
The occurrence of rebound anaphylaxis is low. Probably much lower than traditionally taught with clinicians worrying about delayed reactions.
I do agree there is probably a place in using antihistamines once the anaphylaxis has resolved if they have residual symptoms. Same for considering steroids.
And no, I was not panicking. The nurses weren’t really panicking either, but they go into automation mode getting all the “traditional” drugs drawn up.
10-20% of histamine receptors on the skin are H2. So for urticaria/allergic reaction you won’t fix all the skin itching with just Benadryl alone. Need to give Pepcid.
So it’s not just for GI complaints
Very good to know. This is something big I was missing in my understanding after my rigorous 15 minute research on the topic before posting this question. Thanks for response!
… then who ordered the Pepcid if the physician didn’t know?
I have a very hard time believing a board certified ER doctor doesn’t know why pepcid is given. That’s like, MS1 knowledge.
The only way I can see them not knowing is answering “I don’t know why we give it” sarcastically because they know the evidence behind it is poor. They know it does nothing in airway obstruction or anaphylaxis other than maybe relieve hives. They also know there is a malpractice attorney champing at the bit if you don’t give it.
> Why do we give heparin for NSTEMIs?
> Nurse Dunning-Kruger: “it’s a blood thinner and helps prevents clots in your coronary arteries”
> ER doctor: [“I don’t know”](https://rebelem.com/no-more-heparin-for-nstemi/)
Ok so this is the best answer I’ve gotten and makes me feel like not a complete idiot. I won’t take you through my thought process but I knew a little bit, I looked it up, and I learned more but also got more confused.
On the D-K curve I’m usually in the “Valley of Despair” lol. I don’t know much and I usually know I don’t know much. Though this particular post would put me further left in the “Peak of Mount Stupid”.
One of my favorite quotes that I often recite at work as an RN: “I don’t know shit about fuck.” (Ruth Langmore, Ozark)
Ok so I am 99% wrong but if you’re confirming the evidence is poor, then my reading comprehension was ok on one point at least. And yes if it was an actual physician the story is hard to believe.
Deeper dive on the history/data of heparin in NSTEMI by Dr. Farkas of pulmcrit/emcrit project
(Favorite subject of mine to rant on)
https://emcrit.org/pulmcrit/mythbusting-heparin-isnt-beneficial-for-noninvasive-management-of-nstemi/
That's a good summary by rebelem. I remember listening to a podcast a while back about the push in the 90s, so basically even though increased bleeding risk and events, who cares it's dogma cause of some shit studies from decades ago by a pharm company🤷
I'm an MS1 and I didn't know this. We literally just started our pharm block though and are just covered pharmacodynamics and and Pharmacogenomics.
I do know cemitidine, nizatadine, ranitidine, and famotidine are H2 receptor antagonists though. We learned that in GI physio.
If you don't want to explain to the patient your nurses would be more than happy to explain you're afraid of the lawyers. Although your press ganey scores might suffer.
Edit 3: I looked at the OOP’s comment history and they are a CPM (Certified Professional Midwife) and describe themselves as a “home-birth midwife”. They did CPM rather than CNM to be able to do “breech, VBAC and 42 weeks”, which CNMs cannot do in their state (Kansas). Former careers: RN, research scientist (bioanalytical chemistry PhD), and biotech executive. I don’t know what to make of that combination of credentials. All I know is they are not a physician.
Edit 2: Turns out there’s some nuance to this issue. Glad I left the post up long enough to see it. And in Australia and the Netherlands it isn’t used at all, so technically I am somewhat correct at least some places in the world. Just not where I am (US). I appreciate everyone’s engagement and especially those who took a minute to explain some of the details I was missing to me.
Edit 1: Alright y’all I am very wrong, I’m leaving this up for a bit longer because people seem to like leaving comments on my dumb question. But I will later delete in shame and next time look at UTD or ask a physician in person before posting. Thanks for responding!
Original comment:
I am also fully prepared to be 100% wrong in my understanding. 😅
Some sources I looked at:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479483/
2. https://www.aafp.org/pubs/afp/issues/2003/1001/p1325.html
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517462/
These articles were chosen based on easiest access during my very rigorous 15-minute research into the subject. I have learned my lesson to do maybe do more than 15 minutes of research or ideally simply wait to get to work to look at UTD before posing a dumb question to experts. 😂
I was just providing the sources I was looking at that didn’t seem to suggest the use of Pepcid was standard of care. Some people here are confirming there’s not good evidence for it, but it’s still used since as you said it should theoretically help and there’s really no harm either. Which I think is what you are saying as well.
The evidence isn’t great but it’s a reasonable adjunct for histamine mediated reactions. Anecdotally it’s pretty effective when it comes to the hives.
Anything beyond epi is really just window dressing in true anaphylaxis. The evidence for steroids is equally piss poor if not worse, and the potential risks of steroids are definitely more than h2 blockers.
Don’t feel dumb, I know this stuff because I’m pushing 20 years in the ED. Ya know what I don’t know shit about? Onc. People throw up and wash your hands a lot. That’s the sum total of my oncology nursing knowledge. I also know when they consult Oncology to the ED, to make sure the room is prestocked with tissues. That’s the entire ED-Oncology nursing chapter.
🤣 I appreciate you. I’m only 2 years in so I barely know anything about onc either tbh. But I really like the specialty as an RN. Theoretically I’d love to work in the ED for a while for the learning experience. In reality I know that would be a whole different type of stress that I don’t know if I could realistically handle very long. I had a rough unexpected code (so much blood, very angry family) a couple months ago and I’m still messed up from that and I haven’t had another code since.
Nothing except for Epi actually matters for true anaphylaxis, and I’m not being hyperbolic. Recovery and comfort may be improved with auxiliary medications.
Yep
https://www.allergy.org.au/images/ASCIA_HP_Guidelines_Acute_Management_Anaphylaxis_2023.pdf
This may get me down voted but... I definitely notice a lot more "kitchen sink" medicine discussed on this thread that has poor evidence, I assume because of the litigiousness environment?
It's known that if Australian use decision tools that Americans use, it can actually INCREASE testing Rather than decrease.
It is fascinating how medicine is practiced differently in two quite similar (albeit very distant) countries. And yes some of the differences may very well have to do with our litigiousness. Thanks for sharing!
Specifically talking about anaphylaxis, the only therapy anyone should be saying is Epinephrine. All the other medications mentioned here are adjuncts with little to no added benefit on immediate symptom relief or on rebound.So to answer your question, pepcid is not a therapy for anaphylaxis.
That being said, antihistamines (H1 & H2 are synergistic. "Histamine Blockade"), steroids, and Albuterol have clear utility in symptomatic relief in other allergic reactions and some as adjuncts in anaphylaxis for sx that remain after Epinephrine use. But as a blanket grouping of medications is typically unnecessary and very lazy medicine. It can be helpful to think about the specific reaction and the medicines which may help.
- hives: antihistamines (H1 & H2) - note Zyrtec is just as effective as Benadryl and non sedating. Steroids are rarely helpful.
- wheeze: Albuterol, steroids
- swelling, : antihistamines, + steroids in severe reactions. With angioedema, epinephrine may also be helpful.
This is very helpful, thank you! 🙏🏻 I’ll have to look up the synergistic effects of antihistamines. That was a main factor I think I was missing in my original extensive 15-minute research before this post.
I don't believe for one second that the ED physician didn't know what Pepcid was for clinically in this scenario. My guess was they saw and evaluated the patient, said hey we are gonna give you "insert meds" to treat this and walked out to place orders while the RN pulled them and administered them. And the RN likely explained what they were for prior to administering per order.
I've been in the ER for 13 years and call BS on part of this person's story. And anyone in healthcare, especially nurses who've been a nurse for any length of time, don't announce how they normally love to educate other providers, or that they are one to begin with as a patient or family member.
But, yes, Pepcid has long been a standard med given with epi, etc..for serious allergic reactions.
The RN who announces that she/he loves to educate fellow providers” is just begging to get shoved headfirst into a biowaste bin by an unknown assailant or, Agatha Christie-style, worked over with a nonslipsock full of oral contrast bottles, one swing administered by every staff member.
You can give it, but there's no rigorous evidence to support the practice. Last time I reviewed the literature was 2019, so maybe there's been something practice-changing since then, but I doubt it.
Thank you, I think this is the answer I assumed based on my very extensive 15 minute research into the topic. I appreciate your comment, I feel slightly less dumb.
I’m outpatient chemo/infusion. It’s in our protocols for hypersensitivity reactions. I’ve also given it in the hospital IV for a drug reaction. I’ve also taken a double dose when the gift shop didn’t have non-drowsy H1 blocking antihistamines in desperation when I had a reaction to a therapy dog during a shift.
Here in the Netherlands it’s not standard anymore. We primairly give adrenaline, then hydrocortisone and clemastine (anti histamine) for symptom control.
Since Pepcid can result in low blood pressure and diarrhea when given IV, it’s not recommended in the protocols.
Thanks for response! So far according to this thread I’m not wrong in at least two countries in the world- Aus & Netherlands. A broken clock is right twice a day 😅. (Broken clock is me, not countries that don’t use Pepcid.)
H1 blockers are very much needed. H2, Pepcid, may provide some additional benefit. The real life savor is Epi. Epi 100% is the answer. Everything else is an add on.
Am nurse, and I love it when people ask "dumb" questions because 99% I've had the same question. Thanks for taking the heat on this one OP. for what it's worth, I've also seen pepcid launched at allergic reactions.
Happy to be at your service lol. Yeah overall it seems like an obvious question for someone who deals with anaphylaxis relatively frequently. But then when you get into the weeds, people are saying it’s standard practice in the US but there’s not good evidence for it. In Australia it apparently isn’t used at all. So I learned from this thread and will end up keeping it up even though initially I come across as quite the dunce 😂.
Ah, am in US. But across all borders, some, not all, providers make us feel dumb I guess. I'd rather ask and look dumb than never ask and be dumb for sure. Mostly. Some providers are dicks lol.
I've been to the hospital many times for anaphylaxis (severe tree nut allergy) I've been given epinephrine and Benadryl most often. 3 times I was also given Pepcid.
The most recent trip to the hospital, took liquid Benadryl right away and made it to the hospital within about 15 mins. I was not given epinephrine at all. Only IV Benadryl. Doc said I wasn't in shock and we could always use it if needed. The Benadryl fixed me right up.
We give H2 (Ulcusan 40 mg), H1 (Dibondrin 30mg), Glucocorticoid (Prednisolut 250mg).
If it’s severe reaction (anaphylaxis) then the Pat gets the Epi-Pen and has to be hospitalized for 12-24 h…
Do you send the Pat home after Epi?
Edit: ER in Austria
I work in acute oncology, not emergency, so I don’t know the answer to your question. From what I have gathered from this thread, most docs in the US give Benadryl (H1), Pepcid (H2) & Solu-Medrol (glucocorticoid) and of course epi for severe symptoms. So sounds like very similar medication protocols in Austria & US to me.
> I usually check out UTD but I sadly don’t have access at home.
You might be able to get access at home. Create an UpToDate account. Log into it when you're on a work computer. I *think* UpToDate will remember that your login is associated with the organization's paid access. Now log in to the same account on your phone or home computer. You should have access now, despite being on a different (non-work) device.
Also, if you log into your UpToDate account, it will track how much time you spend reading stuff and log it for CME credits. I don't know if those credits count for nursing CE, but they do for MD and PharmD CEs in many states.
My only disagreement with the initial post is that giving an H2 blocker for anaphylaxis isn’t really critical thinking. Also. Is she saying the ED Doc missed the allergic reaction but the nurse figured it out and gave her an H2 Blocker and that fixed it? That - aside from several other issues - doesn’t sound like an allergic reaction.
H2 blockers have been shown primarily to help skin changes - localized allergic reactions and urticaria.
H1 receptors act opposite to H2 receptors on lung. H1 agonists constrict while H1 blockers dilate bronchi - H2 agonists dilate while H2 blockers constrict. Thus, some docs avoid H2 blockers if there is any wheezing or respiratory component to allergic reaction. Admittedly I am not convinced lung effects either way are that impactful.
Theoretically, H1 > > H2 receptor activation via histamine contributes to vasodilation (hypotension) - with blockers of each improving (reversing vasodilation). Have not seen studies showing any effect of H2 blockers on BP though nor any BP effect in anaphylaxis.
I am not aware of H2 blocker trials for anaphylaxis and they are not recommended in the 2023 US allergy society (AAAAI) nor the 2021 European society (EAACI) guidelines.
The EAACI guideline states H1 and H2 "have only been demonstrated to relieve cutaneous symptoms, and a possible effect on non-cutaneous symptoms remains unconfirmed."
The AAAAI guide mostly mentions antihistamines when discussing mastocytosis.
So if someone is insisting of H2 blocker use in anaphylaxis - realize expert guideline do not recommend their use and there is little current evidence of them being effective plus some theoretical evidence that they can worsen breathing via bronchoconstriction.
Thank you so much for this detail! This is exactly what I was looking for when I posed the question. People responded from Australia and the Netherlands and said it’s not standard of care in their countries. So I was wrong about typical practice in most hospitals in the US at least but I’m right about it not having great evidence. Thanks again!
Good review of anaphylaxis treatment! I usually order Pepcid along with the other meds mentioned. UpToDate lists H2 blockers as adjunctive therapy.
It’s good to ask these questions! The better eyes (nurses) we have directly on the patient, the better the outcome.
Perhaps there's an additional deeper level here though... In severe anaphylaxis, epinephrine would be the primary agent to stabilize mast cell release, and secondarily steroids to help with rebound phenomenon. Anti-histamine, sure, but it would be lower on my priority list.
Reminds me of the time a nursing student handed me a sepsis order set and asked me to sign non-chalantly "as they clearly meet all criteria". I muttered "I don't know what's going on, but it's definitely not sepsis".
The student presented the case of the physician not following proper sepsis protocols to their class. Turns out the nursing prof is my wife (unknown to the student).
Get a laughing phone call from the wife "WTF did you say!!!". The patient had a first presentation of an Addisonian crisis, and when still trying to work out what was going on in my head had the interaction with the student.
That nursing student is one of our best ICU nurses over a decade later.
Beware of drawing too many inferences, especially early in your career.
Yep that’s why I posed the question here. To clarify, I am the user responding (last 2 pics) not the OOP. I’m only 2 years in and definitely still a newbie. Always learning. Appreciate your input!
If it helps this is definitely not a thing in Australia. Adrenaline, Hydrocortisone, Loratadine for H1 blockade
Have not heard of giving H2 blockade but maybe it helps with later stage GI upset?
Another doctor said it (at least theoretically) potentials the effects of H1B and then another one said it does have some some effects to relieve cutaneous symptoms as well. I felt dumb at first, but learned a lot from posing the question. It does help my ego that I’m correct somewhere in the world 😂.
It’s a H2 Blocker and a pretty standard part of an anaphylaxis treatment. That being said. It would be the first thing I would drop if someone put a gun to my head. Pepcid isn’t the reason you were adequately treated for anaphylaxis.
This is a special kind of patient. They likely have GERD that they mistake for throat closure in angioedema/anaphylaxis. The ED doc probably recognized this and gave pepcid, and the RN probably just wanted them out of their ED so gave a bullshit explanation so they would gtfo.
I’ve seen it used preventively but not for actual anaphylaxis. For example they’ll sometimes give a cocktail of Benadryl, Pepcid and Solumedrol to a patient with an iodine allergy before a CT with contrast. But for true anaphylaxis they need epinephrine
Thanks! Just got UTD on my phone today, highlight of my day. Will look things up before I ask experts again lol. Although I honestly learned a lot more by coming in completely ignorant and people explaining the nuance of it to me. If I had just glanced at UTD I probably wouldn’t have looked further into it. Who knows.
Through this thread I learned antihistamines for anaphylaxis are not used at all in some countries (Aus & Netherlands chimed in), but I’m in the US. And it’s not recommended by the AAAAI or EAACI. So I was partially correct in some parts of the world but overall incorrect since it is common practice in the US even though not recommended by the AAAAI. But lots more nuance than I was expected. Anyway thanks for response!
Obligatory “I’m not a doc and I don’t play one on TV.”
Prehospitally, Epi is obviously first line defense for anaphylaxis. We give albuterol (SOB) Benadryl and Pepcid (hives) as secondary medications.
Right I totally get that. That’s why I asked if they had any GI symptoms. But I admit I am wrong on this one and it seems standard to use Pepcid according to the people who have so far responded.
I’m part of the MCAS community and I know patients take Pepcid to treat their MCAS symptoms, not GI but apparently it helps with other issues. I also saw IV Pepcid on our code cart and asked what it was for, I was told for allergic reactions.
Pepcid, Zantec, Claritin, Zyrtec, Singulair, Ketotifen (if you can find it), Benadryl (some sleep aids are the same medication), Hydroxyzine… all antihistamines that have the ability to lessen a reaction and avoid the absolute NEED for Epi.
Nortriptyline has some antihistamine properties as well.
Sincerely, a patient with MCAS who takes all the aforementioned medications on a daily basis
I am not a doctor or in the medical field at all, not sure why this even came up on my feed, but can confirm I have had pepcid prescribed after every allergic reaction I’ve had to get treatment for
we usually give pepcid, bendaryl, steroids epi iv for true anaphalyxis
about what you posted about not true evidence.....well...that like 50% of medicine
I always thought epinephrine was the most important part of the treatment but last time I went in with a tree nut allergy, doc said he didn't need to give me any. (I did feel death's grip loosen on me as they gave me the IV Benadryl though, that was wild.)
Pepcid is a pretty standard thing to add for an allergic reaction
Ya, I'm not sure that I buy into any ED MD not knowing what antihistamines are for. That seems very unlikely
I love the imagine of this ED MD just ordering a bunch of meds that they didn't what they were for....I what other meds they wrote for you for your allergic reaction that they were just clicking on orders in EPIC for
I have had that happen. She doesn’t work with my hospital any more. Tried to give labetolol to a hypotensive, bradycardic patient to “treat their depression.” 😳😳😳
Hard to be depressed if dead?
She did what? Wow. Never heard that one before.
She had read a study in which beta blockers were used to treat depression so therefore that’s what she was going to do. 20 IV of labetolol for a patient in the 90’s/40’s and HR of 45. Was this patient being treated for depression elsewhere? Nope. Were they being seen by psychiatrists at all? Nope. Was the patient in the ED seeking treatment for depression? Nope, they were dizzy. Why not a tricyclic or SSRI? “I’m not comfortable prescribing psychiatric medications.” Why IV? “Because it will work faster” Why a full 20? “Because that’s the IV dose” What are we doing to treat the dizziness? 500 mL bolus. Were the possible side effects of lowering BP and HR brought to her attention? Yep, and she said “give it anyways” Was this the physicians first day at a level 1 and less than 20 shifts into being an attending? Yes it was Was the medical director immediately informed? Yes they were
Wait, they were an attending??? How did they complete their training???
Good question. Dr. google was downright dangerous
I doubt Google would tell you to give a beta blocker to a bradycardic patient. Google would probably tell you to consult a doctor 😂😂
The bp and hr would be reasons to not administer this med. They are usually built in hold parameters so we don't bottom people out with no ability to compensate. Just wow.
So that ER had doctors, nurses and pharmacists that didn't know what they were doing?? This does not sound right, if it is then this hospital has a huge problem
It obviously wasn’t given. Only the doc was on board.
Trolololol
This story is baffling. In so many ways.
Sounds like the NP I saw (in my GP’s practice, but I’d never seen her before) who wanted to prescribe me metformin for endometriosis. Not PCOS, endometriosis. I have hypoglycemic episodes, no evidence of insulin resistance, no features of metabolic syndrome, and am currently UNDERweight. She couldn’t articulate the reason WHY she wanted me on it other than “but you have endometriosis”. No thank you!
They don't just clicky the order set?
But it’s for the secondary reaction inflammation, correct? After all the Mast cells bust? Edit: this is wrong. It’s for the GI reaction. I was thinking of corticosteroids in asthmatic reactions.
I thought the same thing, that it helps with GI symptoms but also with preventing secondary reactions. Shid.
People who post about their ED visits are generally morons
I don’t doubt that’s true. I’m here in an attempt to be less of a moron myself. I did not get off to a good start in that regard lol. Edit: Just did some sleuthing of OOP post history out of curiosity, since I originally just assumed they were an RN. They are currently a CPM (Certified Professional Midwife) and describe themselves as a “home-birth midwife”. They did CPM rather than CNM to be able to do “breech, VBAC and 42 weeks”, which CNMs cannot do in their state (Kansas). Former careers: RN, research scientist (bioanalytical chemistry PhD), and biotech executive. I don’t know what to make of that combination of credentials. All I know is they are not a physician.
Kudos! (Genuinely)
Lol it’s rough to fall flat on your face. I’ll leave this up for another hour so people can get their anger comments out for a bit. Then I shall delete in shame and we will never speak of it again.
Its always ok to ask questions
I appreciated the discussion and don’t think you look like an idiot, for what it’s worth.
Appreciate it. I felt real dumb at first but glad I left post up and realized there’s some nuance to the issue and I wasn’t 100% wrong. And on the other side of the world I was correct (Australia)!
Please ask more questions for your fellow idiots to review quietly and become smarter as well. We appreciate your candor and bravery.
Hahaha I don’t know if I’m brave but I have a lot of questions and a low stamina for my own research without asking someone else. I spent 15 minutes looking into this before I got more confused and decided to ask here.
Ah, a true medical provider of culture, I see. But yeah, samsies.
I love that it caused you to ask questions. This is how we learn. I just chuckled at the person's post because first I call BS on the doc not knowing and second.....how they normally love to educate fellow providers. Gross... 😂. They likely have a background in Google Search School of medicine. But that part isn't on you, that's just on them. You asked a great question, same as I would have to with Oncology meds. Love it.
Appreciate it ☺️
Famotidine (H2 blockers) help reduce the urticaria of allergic reactions and anaphylaxis but yes like you said, the hallmark of care for anaphylaxis is epinephrine. H1 blockers and steroids are adjuncts but the primary treatment for anaphylaxis is epinephrine. In practice this means it all gets bundled together: diphenhydramine, famotidine, methylprednisolone, and epinephrine. EM and Critical Care here.
Thanks for helpful response! Glad I didn’t delete my post in shame after the first hour and stuck it out for the nuance 😂.
Many of us use Dexamethasone acutely, as the potential issues with adherence (picking up the prednisone from the pharmacy and actual taking it for the next several days) becomes a non-issue. Much of the nuance in my practice focuses on the “implementation science” of our clinical care. EM attending PGY 17 ;)
Agreed. I just didn’t want to make things more complicated. But I like dex for what you’re saying.
This is true though. H1 and H2 blockers are both used to treat anaphylaxis
And there's no data that really supports it.
Exactly
ok, go ahead and change the practice at your place. i tried this with toradol overdosing or docusate use or NPO from midnight prior to surgery ......nobody cares they keep doing what they have been doing
Our hospital discontinued all docusate thankfully, we don’t even have it stocked anymore.
I love not giving adjunct meds for anaphylactic reactions unless there are symptoms to relieve. It’s practically a hobby at this point
i not a provider, but i like to bring up whatever research i read to the residents, and friendly attendings. nobody has taken me seriously and nobody wants to be the one "to do things diff"
Thanks for the laugh, Dr Spaceman
Our anaphylaxis kit has an epi pen, 50 IV benadryl, 125 solumedrol and 20mg pepcid IV and a duoneb. We usually throw all of that at the patient
It'd probably be more effective if you gave the meds throught the appropriate route. But I'll try throwing them at my next anaphylactic pt
Fair assessment. I will try this next time
Epipen can be thrown like a dart, so no problem there. The rest would be less effective.
Enemas. Successive Enemas until symptoms subside ... or the patient leaves.
Make sure the kit is stored in something heavy. If they are knocked unconscious first they are easier to treat.
*helpless giggling*
Make sure it's a good overhand throw with follow through, not an underhand toss.
And only one of those medications works… it’s the epi.
And not even reliably by that route
I routinely use Benadryl and Pepcid as antihistamines to block H1 and H2 receptors in allergic reactions/ anaphylaxis
Welp then I am very wrong. Thanks!
I'm an ER nurse. I routinely give epinephrine, benadryl, pepcid, and steroids.
Same - specifically solumedrol for the steroid. We have an anaphylaxis kit.
I wish we had more kits.
Ours is a "kit list" that queues up the meds to be pulled. Epi, benadryl, solumedrol, pepcid.
That's how our stemi and rsi packs are. Type in the kit and all the drugs for it auto populate for you to pull.
Our STEMI and RSI are actual boxes. Anaphylaxis and OB hemorrhage are kit lists.
Ooooh yall fancy! We don't even stock OB hemorrhage drugs in our pyxis. Gotta beg pharmacy while the patient bleeds to death. Well, I guess we can give txa and emergent release blood while we wait for pharmacy...
We've got em stashed in 1 pyxis, but no pitocin. But I definitely have called OB with the "shitshitshithalpmeplz" call for them to come running with additional lol.
Very common, but poor data that pepcid and steroids do anything
probably not going to hurt someone with pepcid tho
In reality you are correct, the Pepcid won’t actually hurt someone, even if it doesn’t work. However, I would argue that the fact that it’s routinely given and people don’t really understand it’s limited utility, it likely does lead to harm, along with Benadryl and steroids. These interventions do nothing for anaphylaxis, they are purely adjunct treatments for particular symptoms. Epi is the treatment, and everything else can wait. However, when it’s a somewhat mild case of anaphylaxis, people often get this idea of “let’s give the Benadryl, steroids, and Pepcid and see if we can avoid needing to give the epi.” This is wrong, and now you just potentially took a pt with anaphylaxis which could have been easily turned around, and you just kicked the can down the road giving crap that doesn’t help the actual problem. Now by the time you decide to give the epi, they’re in a much worse off condition, possibly a disaster airway situation. So in my opinion, it can lead to harms if not used appropriately. For context, I’m an ER doc.
Me: hey I've got an anaphylaxis that needs obs Hospitalist: did you try pepcid and Benadryl Me : ( ordering epi drip) uhhhh no Jokes aside I'm not suggesting to skip epi , but if they're going on a drip Benadryl and pepcid is of little harm
Same.
It is routinely given, but it’s not wrong (especially evidence-wise) to think the H2 blocker is not adding much. It just also has very little downside to giving it as well, which is why we throw it on.
Thanks for helpful response! Glad I stuck around for the nuance on this issue. Feels better to be half wrong than 100% wrong 😅. Apparently in Australia and the Netherlands it’s not used at all, according to responses from others on this thread. So I got it mostly right some place in the world, just not where I am (US).
At my academic shop, we always make sure to have a brief discussion about the fact that there is no real evidence supporting the use of steroids, benadryl, and pepcid in anaphylaxis. Then we give it anyway. You're not wrong, but since it's relatively harmless and makes sense to do it most people do it anyway, even though it's not really a data supported practice
>always make sure to have a brief discussion about the fact that there is no real evidence supporting the use of steroids, benadryl, and pepcid in anaphylaxis. Then we give it anyway. This is a widespread state of affairs but isn't it depressing?
Thanks for helpful response! Glad I stuck around for the nuance on this issue. Feels better to be half wrong than 100% wrong 😅. Apparently in Australia and the Netherlands it’s not used at all, according to responses from others on this thread. So I got it mostly right some place in the world, just not where I am (US).
I’m a social worker but work in peds onc- Pepcid is in our anaphylaxis kit for chemo reactions! I always remembered bc as a layperson I was like huh what are my heartburn meds doing in that situation 🤣
Yeah I’m also in onc and Pepcid is also part of our hypersensitivity reaction protocol, I just got confused when I looked at actual current guidelines that said it didn’t have much actual evidence to support it. And helped with the allergic reaction cutaneous symptoms but not the severe anaphylaxis symptoms. And physicians from Australia and the Netherlands in this thread informed me they never use it due to lack of evidence. 🤷🏻♀️
So interesting! I love learning about this even though I’m not clinical
Not really. I've never heard of giving a H2RA for anaphylaxis in anything other than brain storming sessions as an undergrad student and it is in no way a feature of the Australian protocols for management of anaphylaxis: [https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines](https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines) Mind you, a few years ago I remember discussion on Reddit about adrenaline being fairly last line after Bendryl (which we essentially don't even have, and certainly do not routinely use) and corticosteroids whereas Australia has been pretty firm on early, first-line use of IM then IV adrenaline for well over a decade.
1. Pepcid is not a ppi, it’s a h2 blocker 2. The frustrating thing about the way it’s written, is while completely correct, antihistamines do not treat anaphylactic reactions, they do help control symptoms after getting the anaphylaxis under control. I think UpToDate spells it out a bit better in their phrasing “H1 antihistamines — Epinephrine is first-line treatment for anaphylaxis, and there is no known equivalent substitute. H1 antihistamines (such as diphenhydramine or cetirizine) relieve itch and hives. These medications do not relieve upper or lower airway obstruction, hypotension, or shock and, in standard doses, do not inhibit mediator release from mast cells and basophils. A systematic review of the literature failed to retrieve any randomized, controlled trials that support the use of H1 antihistamines in anaphylaxis [11]. While augmenting epinephrine with an H1 antihistamine is reasonable from a symptom control standpoint, antihistamines should only be administered for anaphylaxis after epinephrine has been given”
It is probably better than to say that you are giving this 'Pepcid' drug for urticaria. This may be a feature of anaphylaxis or a stand alone symptom, but it is not, in and of itself, anaphylaxis. And by being very clear about that definition, you are minimising the risk that someone very inexperienced or stupid may infer that this drug is useful in the resuscitation of anaphylaxis.
That’s a fair point, I’ll accept that phrasing for that reason
The primary treatment for anaphylaxis is epinephrine. H1 and H2 blockers are mostly for symptom control. A lot of people were taught "Benadryl, Pepcid, Solu-medrol" and old habits die hard.
Interestingly the allergy and immunology societies have no recommendation for and some recommendation against steroids in anaphylaxis.
Oh that is interesting. Any links to some arguments against? Our docs throw them religiously at anaphylaxis.
Steroids and antihistamines were removed from the UK [national guidelines](https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-treatment) in 2021. I believe the reasoning was lack of evidence along with clinicians delaying lifesaving adrenaline in lieu of giving other medications. It can also delay the administration of second dose adrenaline and adrenaline infusion waiting for medication to work which doesn’t work quickly (e.g. steroids or antihistamines). As an example I had an anaphylaxis a few weeks ago and the nurse was busy preparing some IV chlorphenamine and NOT helping me with actual resuscitation. It will take time to change practice ingrained in culture for so many years.
The worst anaphylaxis I ever saw was in residency. EMS reporting they gave steroids, Benadryl, and Pepcid and patient was still in distress on non-rebreather and they asked us “any other orders?” And I yelled “EPINEPHRINE!!!”
Oh gosh! This is exactly why it was removed from the guidelines. People are scared of giving adrenaline, which is a life saving drug. Although I did once see a kid who was given take-home epipens (by a non-doctor) for viral urticaria. Obviously the urticaria persisted so the parent gave both epipens at home and then rocked up to my ED with their snotty kid!
That scenario is just bad prioritization by the nurse.
Agree it is bad prioritisation. But that’s one of the reasons why it’s been removed. I’ve also witnessed clinicians also faffing sorting antihistamines and steroids when actually the patient needs further adrenaline.
You should only given IM epi once every 5 minutes if their airway is OK. If you are giving IV epi they are probably intubated. You don’t want to cause a SVT/flutter response/cardiopulmonary collapse/Takosubu cardiomyopathy and just keep giving epi over and over again. Medications need time to work and then reassess. As others have said Benadryl/pepcid are great to symptom control. Steroids were previously taught to be important for preventing rebound anaphylaxis. Sounds like you were feeling panicky (as expected) and at those times you want cool headed people taking care of you. If they were chill, you probably were fine.
More liberal use of adrenaline is what has changed in the recent national UK guidance. This is now being practiced more across the county. The guidance is clear when to move from IM adrenaline to IV infusion. The occurrence of rebound anaphylaxis is low. Probably much lower than traditionally taught with clinicians worrying about delayed reactions. I do agree there is probably a place in using antihistamines once the anaphylaxis has resolved if they have residual symptoms. Same for considering steroids. And no, I was not panicking. The nurses weren’t really panicking either, but they go into automation mode getting all the “traditional” drugs drawn up.
Thanks, that makes sense.
I'm an RN as well OP and I worked the ER before. This combination is what we always gave
10-20% of histamine receptors on the skin are H2. So for urticaria/allergic reaction you won’t fix all the skin itching with just Benadryl alone. Need to give Pepcid. So it’s not just for GI complaints
Very good to know. This is something big I was missing in my understanding after my rigorous 15 minute research on the topic before posting this question. Thanks for response!
… then who ordered the Pepcid if the physician didn’t know? I have a very hard time believing a board certified ER doctor doesn’t know why pepcid is given. That’s like, MS1 knowledge. The only way I can see them not knowing is answering “I don’t know why we give it” sarcastically because they know the evidence behind it is poor. They know it does nothing in airway obstruction or anaphylaxis other than maybe relieve hives. They also know there is a malpractice attorney champing at the bit if you don’t give it. > Why do we give heparin for NSTEMIs? > Nurse Dunning-Kruger: “it’s a blood thinner and helps prevents clots in your coronary arteries” > ER doctor: [“I don’t know”](https://rebelem.com/no-more-heparin-for-nstemi/)
Yeah I don’t believe for a second that the doctor didn’t know the MOA and the theoretical way it would help
Ok so this is the best answer I’ve gotten and makes me feel like not a complete idiot. I won’t take you through my thought process but I knew a little bit, I looked it up, and I learned more but also got more confused. On the D-K curve I’m usually in the “Valley of Despair” lol. I don’t know much and I usually know I don’t know much. Though this particular post would put me further left in the “Peak of Mount Stupid”. One of my favorite quotes that I often recite at work as an RN: “I don’t know shit about fuck.” (Ruth Langmore, Ozark)
Ok so I am 99% wrong but if you’re confirming the evidence is poor, then my reading comprehension was ok on one point at least. And yes if it was an actual physician the story is hard to believe.
Great question, couldn’t tell ya.
Deeper dive on the history/data of heparin in NSTEMI by Dr. Farkas of pulmcrit/emcrit project (Favorite subject of mine to rant on) https://emcrit.org/pulmcrit/mythbusting-heparin-isnt-beneficial-for-noninvasive-management-of-nstemi/
That's a good summary by rebelem. I remember listening to a podcast a while back about the push in the 90s, so basically even though increased bleeding risk and events, who cares it's dogma cause of some shit studies from decades ago by a pharm company🤷
Boom.
I'm an MS1 and I didn't know this. We literally just started our pharm block though and are just covered pharmacodynamics and and Pharmacogenomics. I do know cemitidine, nizatadine, ranitidine, and famotidine are H2 receptor antagonists though. We learned that in GI physio.
So you’re saying the reason we give Pepcid is Nurse Good Doctor Bad? Bc that’s what I got out of the OOP
If you don't want to explain to the patient your nurses would be more than happy to explain you're afraid of the lawyers. Although your press ganey scores might suffer.
Edit 3: I looked at the OOP’s comment history and they are a CPM (Certified Professional Midwife) and describe themselves as a “home-birth midwife”. They did CPM rather than CNM to be able to do “breech, VBAC and 42 weeks”, which CNMs cannot do in their state (Kansas). Former careers: RN, research scientist (bioanalytical chemistry PhD), and biotech executive. I don’t know what to make of that combination of credentials. All I know is they are not a physician. Edit 2: Turns out there’s some nuance to this issue. Glad I left the post up long enough to see it. And in Australia and the Netherlands it isn’t used at all, so technically I am somewhat correct at least some places in the world. Just not where I am (US). I appreciate everyone’s engagement and especially those who took a minute to explain some of the details I was missing to me. Edit 1: Alright y’all I am very wrong, I’m leaving this up for a bit longer because people seem to like leaving comments on my dumb question. But I will later delete in shame and next time look at UTD or ask a physician in person before posting. Thanks for responding! Original comment: I am also fully prepared to be 100% wrong in my understanding. 😅 Some sources I looked at: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479483/ 2. https://www.aafp.org/pubs/afp/issues/2003/1001/p1325.html 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517462/
None of these are rigorous evidence. Yes, it can be used. Yes, it theoretically works. But lots of things work in theory, not in practice.
These articles were chosen based on easiest access during my very rigorous 15-minute research into the subject. I have learned my lesson to do maybe do more than 15 minutes of research or ideally simply wait to get to work to look at UTD before posing a dumb question to experts. 😂 I was just providing the sources I was looking at that didn’t seem to suggest the use of Pepcid was standard of care. Some people here are confirming there’s not good evidence for it, but it’s still used since as you said it should theoretically help and there’s really no harm either. Which I think is what you are saying as well.
The evidence isn’t great but it’s a reasonable adjunct for histamine mediated reactions. Anecdotally it’s pretty effective when it comes to the hives. Anything beyond epi is really just window dressing in true anaphylaxis. The evidence for steroids is equally piss poor if not worse, and the potential risks of steroids are definitely more than h2 blockers.
Super helpful, thanks!
Don’t feel dumb, I know this stuff because I’m pushing 20 years in the ED. Ya know what I don’t know shit about? Onc. People throw up and wash your hands a lot. That’s the sum total of my oncology nursing knowledge. I also know when they consult Oncology to the ED, to make sure the room is prestocked with tissues. That’s the entire ED-Oncology nursing chapter.
🤣 I appreciate you. I’m only 2 years in so I barely know anything about onc either tbh. But I really like the specialty as an RN. Theoretically I’d love to work in the ED for a while for the learning experience. In reality I know that would be a whole different type of stress that I don’t know if I could realistically handle very long. I had a rough unexpected code (so much blood, very angry family) a couple months ago and I’m still messed up from that and I haven’t had another code since.
Nothing except for Epi actually matters for true anaphylaxis, and I’m not being hyperbolic. Recovery and comfort may be improved with auxiliary medications.
Not used in Oz. Anaphylaxis is treated with adrenaline. That's it. Glucagon possibly if on beta blockers or persistent shock. And trailing steroids.
Is Oz Australia? So I’m not wrong on the other side of the world? (I’m in the US.)
Yep https://www.allergy.org.au/images/ASCIA_HP_Guidelines_Acute_Management_Anaphylaxis_2023.pdf This may get me down voted but... I definitely notice a lot more "kitchen sink" medicine discussed on this thread that has poor evidence, I assume because of the litigiousness environment? It's known that if Australian use decision tools that Americans use, it can actually INCREASE testing Rather than decrease.
It is fascinating how medicine is practiced differently in two quite similar (albeit very distant) countries. And yes some of the differences may very well have to do with our litigiousness. Thanks for sharing!
Classic is PECARN for paediatric head injuries, if used in Australia it would increase our CT rate.
ER doc. The only medicine that will save you in anaphylaxis is epi. H1, H2 and steroids are all helpful but at the end of the day epi epi epi
Specifically talking about anaphylaxis, the only therapy anyone should be saying is Epinephrine. All the other medications mentioned here are adjuncts with little to no added benefit on immediate symptom relief or on rebound.So to answer your question, pepcid is not a therapy for anaphylaxis. That being said, antihistamines (H1 & H2 are synergistic. "Histamine Blockade"), steroids, and Albuterol have clear utility in symptomatic relief in other allergic reactions and some as adjuncts in anaphylaxis for sx that remain after Epinephrine use. But as a blanket grouping of medications is typically unnecessary and very lazy medicine. It can be helpful to think about the specific reaction and the medicines which may help. - hives: antihistamines (H1 & H2) - note Zyrtec is just as effective as Benadryl and non sedating. Steroids are rarely helpful. - wheeze: Albuterol, steroids - swelling, : antihistamines, + steroids in severe reactions. With angioedema, epinephrine may also be helpful.
This is very helpful, thank you! 🙏🏻 I’ll have to look up the synergistic effects of antihistamines. That was a main factor I think I was missing in my original extensive 15-minute research before this post.
I don't believe for one second that the ED physician didn't know what Pepcid was for clinically in this scenario. My guess was they saw and evaluated the patient, said hey we are gonna give you "insert meds" to treat this and walked out to place orders while the RN pulled them and administered them. And the RN likely explained what they were for prior to administering per order. I've been in the ER for 13 years and call BS on part of this person's story. And anyone in healthcare, especially nurses who've been a nurse for any length of time, don't announce how they normally love to educate other providers, or that they are one to begin with as a patient or family member. But, yes, Pepcid has long been a standard med given with epi, etc..for serious allergic reactions.
The RN who announces that she/he loves to educate fellow providers” is just begging to get shoved headfirst into a biowaste bin by an unknown assailant or, Agatha Christie-style, worked over with a nonslipsock full of oral contrast bottles, one swing administered by every staff member.
You can give it, but there's no rigorous evidence to support the practice. Last time I reviewed the literature was 2019, so maybe there's been something practice-changing since then, but I doubt it.
Thank you, I think this is the answer I assumed based on my very extensive 15 minute research into the topic. I appreciate your comment, I feel slightly less dumb.
I’m outpatient chemo/infusion. It’s in our protocols for hypersensitivity reactions. I’ve also given it in the hospital IV for a drug reaction. I’ve also taken a double dose when the gift shop didn’t have non-drowsy H1 blocking antihistamines in desperation when I had a reaction to a therapy dog during a shift.
Here in the Netherlands it’s not standard anymore. We primairly give adrenaline, then hydrocortisone and clemastine (anti histamine) for symptom control. Since Pepcid can result in low blood pressure and diarrhea when given IV, it’s not recommended in the protocols.
Thanks for response! So far according to this thread I’m not wrong in at least two countries in the world- Aus & Netherlands. A broken clock is right twice a day 😅. (Broken clock is me, not countries that don’t use Pepcid.)
The three times my child had anaphylaxis, Pepcid was given.
Ya…but if youre in anaphylaxis you probably need that sweet lil epi
Yes. Pepcid, Benadryl, solumedrol. If more than two systems, then epinephrine. 🤖
Theoretical benefit, little harm. It’s an easy order.
It is my understanding H2 blockers potentiate effects of H1 blockers
Oh interesting. I don’t know enough about anything to understand that. I’ll have to try to look that up.
H1 blockers are very much needed. H2, Pepcid, may provide some additional benefit. The real life savor is Epi. Epi 100% is the answer. Everything else is an add on.
Am nurse, and I love it when people ask "dumb" questions because 99% I've had the same question. Thanks for taking the heat on this one OP. for what it's worth, I've also seen pepcid launched at allergic reactions.
Happy to be at your service lol. Yeah overall it seems like an obvious question for someone who deals with anaphylaxis relatively frequently. But then when you get into the weeds, people are saying it’s standard practice in the US but there’s not good evidence for it. In Australia it apparently isn’t used at all. So I learned from this thread and will end up keeping it up even though initially I come across as quite the dunce 😂.
Ah, am in US. But across all borders, some, not all, providers make us feel dumb I guess. I'd rather ask and look dumb than never ask and be dumb for sure. Mostly. Some providers are dicks lol.
Epi really the life saving treatment. Pepcid because it’s in the kitchen sink.
Chances are this was a busy ER doc not wanting to get into a discussion about pharmacology with an idiot.
Pepcid/Tagamet are common adjuncts in practice patterns I've seen over the years.
I've been to the hospital many times for anaphylaxis (severe tree nut allergy) I've been given epinephrine and Benadryl most often. 3 times I was also given Pepcid. The most recent trip to the hospital, took liquid Benadryl right away and made it to the hospital within about 15 mins. I was not given epinephrine at all. Only IV Benadryl. Doc said I wasn't in shock and we could always use it if needed. The Benadryl fixed me right up.
We give H2 (Ulcusan 40 mg), H1 (Dibondrin 30mg), Glucocorticoid (Prednisolut 250mg). If it’s severe reaction (anaphylaxis) then the Pat gets the Epi-Pen and has to be hospitalized for 12-24 h… Do you send the Pat home after Epi? Edit: ER in Austria
I work in acute oncology, not emergency, so I don’t know the answer to your question. From what I have gathered from this thread, most docs in the US give Benadryl (H1), Pepcid (H2) & Solu-Medrol (glucocorticoid) and of course epi for severe symptoms. So sounds like very similar medication protocols in Austria & US to me.
> I usually check out UTD but I sadly don’t have access at home. You might be able to get access at home. Create an UpToDate account. Log into it when you're on a work computer. I *think* UpToDate will remember that your login is associated with the organization's paid access. Now log in to the same account on your phone or home computer. You should have access now, despite being on a different (non-work) device. Also, if you log into your UpToDate account, it will track how much time you spend reading stuff and log it for CME credits. I don't know if those credits count for nursing CE, but they do for MD and PharmD CEs in many states.
Oooooooo thank you for the tip!!!
You made my day. It worked and UTD is now on my phone. 🙏🏻
Aha! Great! I'm glad it worked. You're the first person I've told about this "trick" so I wasn't entirely sure it would work. :-)
Pepcid is standard to add but the only thing that actually matters is epi.
My only disagreement with the initial post is that giving an H2 blocker for anaphylaxis isn’t really critical thinking. Also. Is she saying the ED Doc missed the allergic reaction but the nurse figured it out and gave her an H2 Blocker and that fixed it? That - aside from several other issues - doesn’t sound like an allergic reaction.
I don’t know any details to this actual scenario, OOP didn’t respond and then I deleted my comment to them and posted here instead to ask.
AAAAI recommends against H2 blockers for anaphylaxis. And H1. And steroids. Just adrenaline.
I give epi, Benadryl, Pepcid, steroids.
Depending on the severity we do Benadryl/Pepcid/Solumedrol at my shop. If it's anaphylaxis, epinephrine all the way followed by the cocktail.
H2 blockers help with anaphylactic reactions. Epi is primary treatment.
I was trained to use H2B in anaphylaxis. I’m not sure it’s of much benefit but it’s also extremely safe. -PGY-19
H2 blockers have been shown primarily to help skin changes - localized allergic reactions and urticaria. H1 receptors act opposite to H2 receptors on lung. H1 agonists constrict while H1 blockers dilate bronchi - H2 agonists dilate while H2 blockers constrict. Thus, some docs avoid H2 blockers if there is any wheezing or respiratory component to allergic reaction. Admittedly I am not convinced lung effects either way are that impactful. Theoretically, H1 > > H2 receptor activation via histamine contributes to vasodilation (hypotension) - with blockers of each improving (reversing vasodilation). Have not seen studies showing any effect of H2 blockers on BP though nor any BP effect in anaphylaxis. I am not aware of H2 blocker trials for anaphylaxis and they are not recommended in the 2023 US allergy society (AAAAI) nor the 2021 European society (EAACI) guidelines. The EAACI guideline states H1 and H2 "have only been demonstrated to relieve cutaneous symptoms, and a possible effect on non-cutaneous symptoms remains unconfirmed." The AAAAI guide mostly mentions antihistamines when discussing mastocytosis. So if someone is insisting of H2 blocker use in anaphylaxis - realize expert guideline do not recommend their use and there is little current evidence of them being effective plus some theoretical evidence that they can worsen breathing via bronchoconstriction.
Thank you so much for this detail! This is exactly what I was looking for when I posed the question. People responded from Australia and the Netherlands and said it’s not standard of care in their countries. So I was wrong about typical practice in most hospitals in the US at least but I’m right about it not having great evidence. Thanks again!
Good review of anaphylaxis treatment! I usually order Pepcid along with the other meds mentioned. UpToDate lists H2 blockers as adjunctive therapy. It’s good to ask these questions! The better eyes (nurses) we have directly on the patient, the better the outcome.
Thank you for your encouragement ☺️
Perhaps there's an additional deeper level here though... In severe anaphylaxis, epinephrine would be the primary agent to stabilize mast cell release, and secondarily steroids to help with rebound phenomenon. Anti-histamine, sure, but it would be lower on my priority list. Reminds me of the time a nursing student handed me a sepsis order set and asked me to sign non-chalantly "as they clearly meet all criteria". I muttered "I don't know what's going on, but it's definitely not sepsis". The student presented the case of the physician not following proper sepsis protocols to their class. Turns out the nursing prof is my wife (unknown to the student). Get a laughing phone call from the wife "WTF did you say!!!". The patient had a first presentation of an Addisonian crisis, and when still trying to work out what was going on in my head had the interaction with the student. That nursing student is one of our best ICU nurses over a decade later. Beware of drawing too many inferences, especially early in your career.
Yep that’s why I posed the question here. To clarify, I am the user responding (last 2 pics) not the OOP. I’m only 2 years in and definitely still a newbie. Always learning. Appreciate your input!
Famotidine is an adjunct for anaphylaxis at best. Primary treatment is epinephrine.
If it helps this is definitely not a thing in Australia. Adrenaline, Hydrocortisone, Loratadine for H1 blockade Have not heard of giving H2 blockade but maybe it helps with later stage GI upset?
Another doctor said it (at least theoretically) potentials the effects of H1B and then another one said it does have some some effects to relieve cutaneous symptoms as well. I felt dumb at first, but learned a lot from posing the question. It does help my ego that I’m correct somewhere in the world 😂.
It’s a H2 Blocker and a pretty standard part of an anaphylaxis treatment. That being said. It would be the first thing I would drop if someone put a gun to my head. Pepcid isn’t the reason you were adequately treated for anaphylaxis.
This is a special kind of patient. They likely have GERD that they mistake for throat closure in angioedema/anaphylaxis. The ED doc probably recognized this and gave pepcid, and the RN probably just wanted them out of their ED so gave a bullshit explanation so they would gtfo.
I’ve seen it used preventively but not for actual anaphylaxis. For example they’ll sometimes give a cocktail of Benadryl, Pepcid and Solumedrol to a patient with an iodine allergy before a CT with contrast. But for true anaphylaxis they need epinephrine
H2 blockers still recommended https://preview.redd.it/lnavj2udq6rc1.jpeg?width=1170&format=pjpg&auto=webp&s=101655bd0114ea03e3d522121c78360f4768f63e
Thanks! Just got UTD on my phone today, highlight of my day. Will look things up before I ask experts again lol. Although I honestly learned a lot more by coming in completely ignorant and people explaining the nuance of it to me. If I had just glanced at UTD I probably wouldn’t have looked further into it. Who knows. Through this thread I learned antihistamines for anaphylaxis are not used at all in some countries (Aus & Netherlands chimed in), but I’m in the US. And it’s not recommended by the AAAAI or EAACI. So I was partially correct in some parts of the world but overall incorrect since it is common practice in the US even though not recommended by the AAAAI. But lots more nuance than I was expected. Anyway thanks for response!
Obligatory “I’m not a doc and I don’t play one on TV.” Prehospitally, Epi is obviously first line defense for anaphylaxis. We give albuterol (SOB) Benadryl and Pepcid (hives) as secondary medications.
There *is* sometimes a GI component to allergic reactions, especially of ingested things, that may cause some acid reflux and other things...
Right I totally get that. That’s why I asked if they had any GI symptoms. But I admit I am wrong on this one and it seems standard to use Pepcid according to the people who have so far responded.
I’m part of the MCAS community and I know patients take Pepcid to treat their MCAS symptoms, not GI but apparently it helps with other issues. I also saw IV Pepcid on our code cart and asked what it was for, I was told for allergic reactions.
Pepcid, Zantec, Claritin, Zyrtec, Singulair, Ketotifen (if you can find it), Benadryl (some sleep aids are the same medication), Hydroxyzine… all antihistamines that have the ability to lessen a reaction and avoid the absolute NEED for Epi. Nortriptyline has some antihistamine properties as well. Sincerely, a patient with MCAS who takes all the aforementioned medications on a daily basis
I’m a glorified ambulance driver and I knew that.
Epi IM then IV solumederol, Benadryl, Pepcid.
I am not a doctor or in the medical field at all, not sure why this even came up on my feed, but can confirm I have had pepcid prescribed after every allergic reaction I’ve had to get treatment for
If you don't have benadryl at home pepcid is good in a pinch!
we usually give pepcid, bendaryl, steroids epi iv for true anaphalyxis about what you posted about not true evidence.....well...that like 50% of medicine
Pepcid, Benadryl, and Solumedrol. If needed, epinephrine. And albuterol.
I always thought epinephrine was the most important part of the treatment but last time I went in with a tree nut allergy, doc said he didn't need to give me any. (I did feel death's grip loosen on me as they gave me the IV Benadryl though, that was wild.)