Diphenhydramine Use in ESRD

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Introduction   

When hearing “end stage renal disease,” what comes to mind? Whether you’re new to nursing or have been a nurse for many years, you have definitely heard of the kidneys and the hard work they do to keep humans functioning and thriving. That said, some people develop severe kidney complications, such as end stage renal disease (ESRD), which can shorten their lifespan and affect their quality of life in severe ways. Diphenhydramine is another popular medicine that you have heard of as well and is a commonly used antihistamine. The information in this course will serve as a valuable resource for nurses of all specialties and backgrounds interested in learning more about the role of diphenhydramine in clients with ESRD.  

Diphenhydramine 

To begin with, diphenhydramine is an over-the-counter (OTC) medication that acts as an antihistamine and is used primarily to manage seasonal allergies, allergic reactions, motion sickness, insomnia, and itching. Diphenhydramine is widely used in America and is one of the most common OTC drugs with various formulations for pediatric, adult, and geriatric populations. It is available via pill, liquid, injection, or intravenous (IV) fluid, but mostly found in pill or liquid forms OTC. Diphenhydramine has been on the USA market for several decades now and is often regarded as a well-tolerated, cost-effective, affordable medicine (1,2,3). 

Pharmacology and Purpose 

Diphenhydramine has a method of action as a histamine receptor (H1) receptor antagonist with partial H1 receptor agonist activity. Since H1 receptors are found in various parts of the body, such as in the uterus, immune cells, and cardiac tissues, diphenhydramine can have systemic effects on the body. Because of this method of action, when someone takes diphenhydramine, that person’s blood vessels become vasodilated, there is increased vascular permeability, and there is the ability for this medicine to cross the blood-brain barrier (BBB). Since diphenhydramine crosses the BBB, side effects, such as drowsiness and central nervous system (CNS) depression, are possible. While diphenhydramine is primarily used to alleviate allergic responses in clients, many people use diphenhydramine to assist with sleeping, itching, and relieving pain, which are things to consider for clients living with ESRD (1,2,4). 

Risks and Benefits in Modern Medicine 

Benefits of diphenhydramine are well-studied, such as management of allergies, insomnia, itching, and pain, all of which are common health complaints. However, despite widespread commercial and medical successes of diphenhydramine, there are risks to every medical intervention. Diphenhydramine can be used to instigate an overdose, causing severe drowsiness, CNS complications, and renal complications, especially if someone has a history of pre-existing health conditions or other medicine use. Diphenhydramine also has a variety of possible side effects, such as constipation, headache, changes in blood pressure, urinary retention, changes in vision, changes in menstrual cycle, and erectile dysfunction. Some more severe side effects can include changes in heart rhythm, seizures, and heat stroke. Because of the varied side effects possible with diphenhydramine, it is important to ask clients the frequency and dosage of the amount of diphenhydramine they are using.  

For instance, a pediatric client taking diphenhydramine as a liquid by mouth will have different dosing requirements compared to an adult who is taking diphenhydramine as a pill by mouth. It is also important to note that these side effects can worsen with alcohol use and in people with renal complications, such as acute kidney injury (AKI) or ESRD. Diphenhydramine is also contraindicated in people who are taking certain CNS depressant medications, such as sedatives or MAO-inhibitors. If a client is suspected of having diphenhydramine toxicity, they need to be transferred or seek emergency care immediately to minimize health complications (1,2). 

End Stage Renal Disease (ESRD) 

ESRD is a chronic, terminal health condition in which someone’s kidneys are not functioning at a sustainable level. Kidneys play a major role in the body’s urination, waste elimination, and fluid management. When kidneys cannot function the ways in which they are intended to do so, that can lead to chronic kidney disease (CKD), which is the precursor to ESRD. ESRD is defined as when a client has a glomerular filtration rate (GFR) of less than 15 mL/min. Many things can cause CKD, such as hypertension, uncontrolled diabetes mellitus, physical trauma, alcohol use, and more. ESRD is a terminal condition because people cannot live without their kidneys, meaning that clients with ESRD receive hemodialysis treatments to help function and as a form of palliative care. Even if someone receives a kidney transplant, that is not a guarantee to return to cure kidney or renal complications. ESRD is often diagnosed by a nephrologist or nephrology specialist provider and has no cure. Lab values and imaging can help assess kidney function and disease progression and prognosis (4).  

Pathology, Complications, and What It Means for Clients and Medicine 

ESRD is a complex chronic health condition that can be caused by many things as stated above. Simply put, the pathology of ESRD can depend on the cause of renal failure itself. For instance, a client with uncontrolled diabetes mellitus can have CKD that progresses to ESRD as a result of unmanaged glucose levels, inability for the kidneys to filter out glucose, and fluid shifts in the body. Another client can have ESRD as a result of renal artery stenosis or renal vein thrombosis that led to CKD and progressed to ESRD. Overall, ESRD is the result of decreasing kidney function and decreased abilities for the kidneys to filter, excrete, and balance fluids. When nephrons in the body are not able to function to their maximum capacity, the body starts to be able to manage fluids less effectively, causing systemic issues for the body’s homeostasis. Things that can exacerbate ESRD include smoking, consuming alcohol, using certain medications, experiencing dehydration, and more.  

Complications of ESRD include needing hemodialysis treatments until death, anemia, electrolyte imbalances (in particular, hyperkalemia), metabolic acidosis, and bone complications. If a client has severe CKD or ESRD, they need to receive hemodialysis to continue to live, as people cannot function without filtration of fluids in their body, making ESRD a complex, chronic health condition that requires intensive management and palliative care intervention and assistance. Presently, in America, it is estimated that at least 100,000 people have ESRD, with exact estimates unknown. ESRD is common among the geriatric population, but can affect anyone of any age. Clients with ESRD receive hemodialysis or can elect to receive a kidney transplant. Even after a kidney transplant, a client with ESRD can be on hemodialysis as well (4).   

Indications for Diphenhydramine Use in End Stage Renal Disease (ESRD) 

Many clients with ESRD use diphenhydramine for various reasons. One reason is that many clients with ESRD receive hemodialysis, which can be painful, cause itching, and cause localized allergic reactions. In particular, hemodialysis can trigger hemodialysis-associated pruritus (HAP), affecting over half of all people receiving hemodialysis. This can severely influence someone’s quality of life, ability to work, thrive with family members and loved ones, experience pain, and sleep. Also, hemodialysis can be costly, raising the concerns of cost when accessing and maintaining health care. Because of the ease of availability of diphenhydramine, many clients can purchase OTC diphenhydramine pills to take after their hemodialysis sessions to reduce the itching and pain. Another reason clients with ESRD can use diphenhydramine is to help with sleeping. Cost, ease of access, and availability are several reasons why clients with ESRD use diphenhydramine.  

That said, because of the varied doses of diphenhydramine and the possibility of diphenhydramine toxicity, overdose, and complications, it is important to ask about the frequency, dosage, and route of diphenhydramine intake among clients with ESRD. Also, chronic use of diphenhydramine without adequate kidney function, especially if a client smokes, drinks alcohol, or has other health conditions, can cause absorption, distribution, and elimination complications, further worsening client health (1,2,3,5,6,7). 

Implications of ESRD and Diphenhydramine Use 

Historically, there is very little evidence-based research on the use of diphenhydramine for ESRD complications since other medications are used as first-line options. For itching, pain, and sleep concerns with ESRD and hemodialysis, many clients are often prescribed a wide variety of medications, such as selective serotonin reuptake inhibitors (SSRIs), leukotriene inhibitors, opioids, or topical steroids. However, there are many reasons why a client cannot tolerate these prescription options. For some, cost is the most pressing barrier, as prescriptions require a medical consult (which often results in a cost or co-pay) and possibility of the medication not being covered by insurance.  

In addition, a client might try a prescription option with little desired therapeutic results or have drug-drug interactions with other medications taking. If there are gaps in care, such as moving to another residence, changes in health insurance or changes in providers, a client could self-discontinue a prescription medication and seek OTC diphenhydramine use given its proximity and cost. Also, some clients might not be able to tolerate SSRIs, opioids, or steroids because of their side effects and lack of desire for continued trial and error, causing further distress and decreased quality of life to the client (1,2,7,8,9,10,11).  

While there have been several studies on other first-line options for managing itching, pain, and complications with ESRD and hemodialysis showing promising results for these options, for many clients, many first-line options are not accessible. Inaccessible nephrology care, lack of telehealth or remote care, cost, caregiving responsibilities, and more affect thousands of people with ESRD. Many clients with ESRD are low-income, struggle with end-of-life care, are not fluent in English, drink alcohol excessively, smoke tobacco, have other chronic health conditions, and have other lifestyle stressors that affect overall health outcomes. When considering the implications for diphenhydramine use in clients with ESRD, it is important to consider social determinants of health and the realities many clients face when accessing nephrology and other palliative care measures (1,2,7,8,9,10,11).  

Nursing Considerations 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of client care in several health care settings. Clients turn to nurses for guidance, education, and support. While the scope of work of nurses can vary state by state and by various workplaces, here are some general recommendations into the role of nurses in placenta uses in modern medicine (1,2,4,5,6,7,9). 

Obtain a Health History 

Take a detailed health history. Often times, obtaining a detailed health history prior is often complex and sometimes dismissed in health care settings, even in cases of possible ESRD. Nurses are the most trusted profession for a reason and are known for their detail to care. Even if there is a possibility of ESRD, making sure you are aware of the client’s health history, desires, and symptoms is a must. If the client is not in an emergent health situation, ask about their urinary habits, signs of fluid retention (such as swelling limbs), how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a client’s complaint is not being taken seriously by other health care professionals, advocate for that client to the best of your abilities. Take the time to establish care with that client.  

Review Medications 

Review medication history at every encounter. One of the main reasons diphenhydramine use with clients with ESRD is overlooked is because clients often do not think that OTC medications need to be included in a medication asking. Whether you are working in outpatient or inpatient care, reviewing health records can be overwhelming. While millions of people take medications, there are many people who take medications and are no longer benefiting from the medication. Ask clients how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history. Make sure to specify if the client is taking any over-the-counter supplements or herbs as well and document the dosage, frequency, and administration route. Make sure you are aware of your facility’s protocol in case of diphenhydramine toxicity and other ESRD sudden complications.  

Education the Client/Family  

Many people, including health care professionals, are not aware of side effects of long-term diphenhydramine use with ESRD. Be willing to educate people on these possible severe side effects of diphenhydramine overuse.    

Be willing to be honest with yourself about your comfort level discussing topics and providing education on medication and medical procedures, including ESRD, hemodialysis, and diphenhydramine. If you are not comfortable discussing something, please refer to another staff member, as nephrology care can be complex. (more on client education later) 

Involve Other Care Team Members 

Communicate the care plan to other staff involved for continuity of care. For several clients, ESRD is a major diagnosis and presents itself with severe life changes. Several clients with ESRD also have several health care providers, such as a primary care provider (PCP), nephrologist, therapist, social worker, and more. Ensure that clients’ records are up to date for ease in record sharing and continuity of care and to avoid any discrepancies in medication history. 

Review Documentation 

Review your documentation and facility protocols regarding ESRD, hemodialysis, and palliative care. If you suspect any complications or discrepancies with documentation, make sure you take time to review it again.  

Monitor Dialysis Progress 

Monitor the client during hemodialysis, especially their vital signs and responses to pain. Hemodialysis is painful for many clients, and many clients report pain during and after the procedure, which is often two to three times a week. Ask about pain and pain management at every encounter to catch any possible early use of diphenhydramine or other pain management intervention needs.  

Ensure that all staff and client is wearing appropriate PPE at all times when performing hemodialysis per your workplace’s protocol.  

Engage in Continuing Education 

Stay up to date on continuing education related to medications, renal health, and hemodialysis, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your clients with the latest information.  

Identify Clients Early 

Truly, it is not possible to look at a client and tell if they are taking diphenhydramine. Some clients take diphenhydramine and other medications and have no side effects. Some clients with ESRD take diphenhydramine and can have changes in their sleep habits, pain levels, and vital signs. Often times, clients might not be aware of the implications of using OTC medications, especially considering the cost and ease of access of many OTC medications like diphenhydramine. Educating and informing clients about medications and taking a detailed history and assessment are duties of a nurse working with clients with ESRD (4,7,8,11). 

Client Education 

Clients should know that ESRD is a chronic health condition with no cure and needs regular health interventions to manage kidney health. If a client is interested in learning more about diphenhydramine and other medication options that can be used during ESRD, the client should be willing to ask questions to their care teams, including their nurses (1,4,6,7,8,11).  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors for diphenhydramine use with ESRD) 
• Tell the health care provider of any existing lifestyle concerns, such as non-prescription drug use, sleeping habits, diet, stress levels, smoking habits, and alcohol use (need to identify lifestyle factors that can influence medication use and therapy interventions) 
• Tell the health care provider if you have any changes to your body, such as trouble with urination, GI complications, pain with movement, increased headache, or increased fatigue (potential placental retention symptoms) 
• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 
• Keep track of your health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality with ESRD complications) 
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options 

Conclusion

Nursing and kidney health are here to stay, especially since several nurses work with ESRD directly in dialysis centers, hospitals, and home health settings across America. While many people unaware of the role of diphenhydramine in ESRD and its influence on kidneys, nurses are the forefront of client care in many settings. From inpatient intensive care unit stays to rural health clinics, nurses are collecting client histories, performing assessments, and educating people on their bodies. Now is the time to make sure you are aware of the various roles of diphenhydramine use in ESRD. 

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