QUESTION: hi,i am 80 year old male who has diabetes and hypertension.i get mild hives 20 0r so fairly gave me hydroxyzine 20mg a kidney function is about 50percent.i have slight prostate enlargement,but no urine problems.they say Benadryl is not good for elderly and hydroxyzine can cause tardive dyskinesia.think zyrtec is safest and best for hives or another antihistimine

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ANSWER: Dear Howard,
Thank you for your question.  In a nutshell, Howard, your comments are accurate.  I'll try to elaborate further for you and offer some helpful hints along the way.

My first question to you is whether you are under the care of a dermatologist, or has your condition ever been assessed by a dermatologist?  The reason I ask this, Howard, is that although family doctors (general practitioners) hold a wealth of knowledge, a dermatologist is the foremost expert.  If you are experiencing hives, or urticaria, so frequently, it would be wise to be formally examined by a specialist for a proper diagnosis.  They may be able to determine the underlying cause of the hives.  If the trigger factors can be identified, then you will be able to avoid them...problem solved; no need to worry about unnecessary medications or their side effects.  However, this is sometimes easier said than done.  None-the-less, you'd have the best chance of identifying these trigger factors under the care of a specialist dermatologist.  This should be considered your first-line point of attack.

Antihistamines are commonly used to treat the intense itch that accompanies hives. And again, a dermatologist would be in the best position to decide which one is best suited to your condition and safest for your age and concomitant medical conditions.  In the meantime, I'd be happy to offer you my professional opinion.  In all honesty, hydroxyzine is not my favorite.  Hydroxyzine belongs to an older class of antihistamines known to cause sedation (ie. sedative antihistamines, to which, Benadryl also belongs).  These should be avoided in older patients.  It also has other side effects such as hypotension, dizziness, constipation, urinary retention, dry mouth, confusion.  As we get older, we tend to become more sensitive to these effects, particular when we have other medical conditions and/or are on other medications which can compound these problems.  Hypotension, dizziness and sedation can increase the risk of falls, for example.  Are you on any other medications, Howard?  For diabetes perhaps?  These should be fine, but blood pressure medications can increase the risk of falls, dizziness and tiredness.  Avoid alcohol due to the enhanced sedative effects.  Although your water-works is functioning just fine at the moment, hydroxyzine could certainly have an adverse effect here.  Yes, there is a risk of tardive dyskinesia, which as the term suggests, typically occurs after long-term use.  Just how long exactly is a bone of contention.  Some say years, others claim months.  And the incidence certainly is greater amongst the elderly.

In hydroxyzine's defense, compared to some of the other drugs in its class, it is purported to have less incidence of constipation, urinary retention, confusion and dry mouth.  It also has an anti-anxiety type property, which may make it favorable under certain circumstances.  Your dermatologist would be in the best position to decide whether the risks of hydroxyzine outweigh its benefits in your case.  Note, Howard, that the dose of 20mg daily seems appropriate for your level of kidney function.      

From a primary health care perspective, I would be inclined to recommend a non-sedating antihistamine (often referred to as 'less' sedating these days).  These tend to have fewer side effects; negligible sedation, constipation, confusion, urinary retention etc.  They are preferred for use in the older population and for those with urinary retention or prostatism.  They should, in theory, be as effective in treating the itch associated with hives; although some disagree.  Have you tried a non-sedating antihistamine before, Howard?  Did it work for you?  Yes, Zyrtec is a great example.  The dosage will need to be reduced for your level of kidney function, but is still entirely manageable.  The usual adult dose of Zyrtec (cetirizine) is 10mg daily.  With your level of renal function, a dose of 5mg daily (half a tablet) may be appropriate.  There are other non-sedating antihistamines within this class, the doses of which can all be tailored to your renal function.  

Howard, you may have tried topical preparations eg, antihistamines, corticosteroid creams and other anti-itch agents. These may help, but are not believed to be all that effective in the treatment of hives.  In addition, topical steroids are associated with side effects, particularly when used long-term.  Other non-pharmacological options to consider (other than avoiding potential trigger factors) include applying cold compresses, reducing room temperature, and wearing loose fitted clothing made of natural fibers (eg, cotton).     

Note also that severe flare-ups may necessitate a short course of an oral corticosteroid.  See your doctor if symptoms become particularly unmanageable as these agents require a prescription for dispensing.  There are other medications which a doctor may prescribe as preventative treatment such as a very low dose antidepressant.  These are not used for their antidepressant effects, but rather for their antihistamine properties.  Note, however, that these can also cause similar side effects to those mentioned above, and may ultimately be inappropriate for you.  Once again, the doctor is in the best position to decide whether these risks outweigh the benefits.

So, in summary, Howard, see a dermatologist if you can.  Try to determine the underlying cause of your hives and avoid these trigger factors if at all possible.  Seek appropriate treatment based upon dermatologist's recommendations.  Failing that, a non-sedating antihistamine such as Zyrtec would seem best and safest for you.  Practice some non-drug measures to deal with your symptoms.  

I wish you all the best, Howard.  Let me know how it all goes, and if you would like me to clarify anything further, please do not hesitate to ask.

---------- FOLLOW-UP ----------

QUESTION: many thanks for the long and nicely phrased answer.i do have diabetes and take eliquis for my atrial fibberation.the dermatologist are clueless I saw 3 they could not help me.i went to a alleregist he said 90

thanks for the answer.i have diabetes and hypertension.i also have a-fib for which I take eliquis.i went to 3 dermatologists about hives,they are cluesless.finally went to alleregy doctor.he said they don't know what causes hives,and I take eliquis,lisinopril,amploninde cancel channel blockeranf Flomax ambien and Xanax.i don't think eliquis causes hives.the alleregist put me on hydroxyzine.zyrtec is not kidney friendly as far as I read.would 5mg of zertec be enough  ofone dermatologist said allegra but I don't know if that is think 5mg  of zyrtec would be suffient to prevent hives?i don't have kidney problems per sey but at 80 I figure 50% of kidney function.zyrtec does not cause tardive Benadryl works but at my age its I put myself in your hands and see what you can suggest/thanks for the pleasant letter


Dear Howard,
I'm sorry you didn't have much luck with the dermatologists.  I can only imagine how frustrating this must be for you.

In theory, any medication can cause allergic, rash, itch or hives-like symptoms.  Even antihistamines, funnily enough!!!  But yes, some are more prone than others.  Do you think that your problem with hives started around about the same time that one of your medications was commenced?  This might be worth considering.  Note also that sometimes reactions such as these may even be delayed.  Of the medications that you take, amlodipine is known to 'commonly' cause rash as a side effect.  Have a think about when this was started.  But remember, it may or may not be the cause of your hives.  In fact, finding the trigger factor for urticaria and hives is notoriously difficult.

Yes, generally speaking, sedating antihistamines don't require dosage adjustment in renal impairment (hydroxyzine being the exception).  Notwithstanding this, non- (or less-) sedating antihistamines are preferred as they are better tolerated.  Their doses simply require reduction.  It might seem a low dose of Zyrtec, but the idea is that because the kidneys won't be removing the drug from the body as well (or as quickly), an otherwise full adult dose has the risk of accumulating.  The problem with this is that you will be at greater risk of side effects.  The rate of effectiveness, however, will not be increased.  Non-sedating antihistamines are such because they don't pass the membranes that protect the brain to cause sedation.  However, they lose this specificity as the dose is increased (or when accumulation occurs).

Yes, as we age, our renal function declines.  But you are assuming that yours is at 50%.  Next time you have a blood test, remind your Dr to check renal function.  Kidney function is quantifiable, and a test can uncover your true kidney filtration rate.  Once this is known, your Dr or pharmacist will be able to recommend, with a high degree of certainty, the most accurate dosage for you.  Howard, you may want to check with your doctor as such a test may already have been performed.  It is a common enough test.

Benadryl has the side effects I mentioned.  Remember that Ambien and Xanax both cause drowsiness.  Taking a sedating antihistamine, such as Hydroxyzine, may compound this effect.  This can lead to drowsiness, fatigue, confusion, falls etc etc.  I think it may be best to stick to non-sedating antihistamines.

Allegra (fexofenadine) is another non-sedating antihistamine, and also worth considering.  Generally a higher dose is required for its use in urticaria.  With renal impairment, it may be worth starting at 60mg daily and monitoring for side effects.  

Just a final thought.  Try using a non-allergenic laundry detergent, and ensure your garments are thoroughly rinsed.

I sincerely hope things work out for you, Howard.  All the very best.  


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Gisella Campanelli


I am able to answer questions relating to pharmaceuticals, therapeutic regimes and primary health care. This includes offering advice on drug indications, dosages, and disease state management. I can also identify side effects, drug interactions and contra-indications, and offer recommendations on ways to mitigate these. I can diagnose minor illnesses and suggest appropriate over-the-counter remedies and/or preventive healthcare tips. I can recognize cardinal symptoms which would otherwise require referral to a medical practitioner.


I am a registered pharmacist in Australia, and I have practiced in a hospital pharmacy for over thirteen years. My clinical specializations lie within the areas of psychiatry and general medicine (including gastroenterology, respiratory, endocrinology, neurology, infectious diseases, gerontology, dermatology). I self-managed the training program for pharmacy interns in preparation for their final registration exams, and I have worked for the Pharmacy Board of Australia as an examiner and exam writer.

I hold a Bachelor of Pharmacy from the Victorian College of Pharmacy, Monash University, and I am board-registered to practice within Australia. I also hold a Master's degree in an unrelated field (art conservation).

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