SGEM#506: Aww I’m Itchy…and I need a Second Generation Antihistamine

First-generation antihistamines like diphenhydramine are frequently used in emergency departments for allergic symptoms, yet they carry significant risks of sedation, anticholinergic side effects, and unpredictable behavioral changes. Dr. Stephanie Kubala, an allergy and immunology specialist, advocates for transitioning to second-generation antihistamines such as cetirizine, which offer longer-acting, better-tolerated relief. A recent quality improvement initiative at Yale New Haven Children's Hospital successfully reduced first-generation antihistamine use by implementing a bundled approach: staff education, improved medication availability in dispensing machines, and updated clinical pathways. While this shift did not negatively impact emergency department revisit rates or length of stay, it highlights the necessity of systemic changes over simple education to ensure reliable clinical practice. Ultimately, while first-generation agents remain useful for specific sedative or anxiolytic needs, they should no longer be the default reflex for routine itch control.