Histamine Modulators




(1)
Department of Anesthesiology, Tulane Medical Center, New Orleans, LA, USA

(2)
Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA

 



 

Michael Yarborough






Introduction


Discovery of certain chemicals to counteract the effects of histamine occurred in the early twentieth century. The development of a drug that would alleviate allergic reactions such as itchy, watery eyes, and a runny nose from a cold or hay fever had an astronomical effect on the medical community. By the 1950s, antihistamines were being mass-produced in the USA and prescribed extensively as the drug of choice for those suffering from allergies. The public perceived antihistamines as the “wonder drug” and with the misconception that it was a “cure all” to the common cold. Eventually, scientist began to discover additional indications for the use of antihistamines. These compounds continue to be one of the most universal drugs lining the shelves of local pharmacies. However, the plethora of roles that antihistamines play in the treatment of the human condition is much more extensive, including suppression of allergy symptoms, sedative agents, and antiemetic actions to name a few.


Drug Class and Mechanism of Action


Histamine is involved in local immune responses as well as regulation of physiologic functions in the gut. It can also act as a neurotransmitter. Histamine is made and released by different cells, i.e., basophils, mast cells, platelets, histaminergic neurons, lymphocytes, and enterochromaffin cells. It is stored in vesicles or granules awaiting release upon stimulation [1]. As part of an immune response to foreign pathogens, histamine increases the permeability of capillaries to white blood cells and other proteins in order to allow them to engage foreign invaders in the infected tissues. Clinical effects of histamine result in increased vascular permeability and leakage of plasma proteins, causing fluid to escape from capillaries into the tissues [2]. This leads to the classic symptoms of an allergic reaction such as a localized rash, itching, puffy and watery eyes, nasal congestion, and rhinorrhea.

There are four known human histamine receptors that have been identified (Table 22.1). These receptors belong to the G-protein-coupled receptors family. They are signified as H1, H2, H3, and H4. Stimulation of the H1 receptor can activate intracellular signaling pathways leading to the development of classic allergic symptoms [1].


Table 22.1
Histamine receptors classification




























Receptor type

Tissue location

Intracellular function

H1

Airway and vascular smooth muscles, endothelial, central nervous system (nerve cells), neutrophils, eosinophils, monocytes

Cause bronchial smooth muscle contraction, separation of endothelial cells causing hives, pain, and itching. Allergic reaction symptoms, motion sickness, and regulation of sleep

H2

Nerve cells, vascular smooth muscles and parietal cells, hepatocytes, endothelial cells, epithelial cells, neutrophils, eosinophils, monocytes

Vasodilation and stimulation of gastric acid secretion

H3

Histaminergic neurons, eosinophils. Found primarily in the central nervous system, low expression in peripheral tissues

Inhibits histamine release and synthesis. Decreases release of serotonin, acetylcholine, and norepinephrine

H4

High expression in bone marrow and peripheral hematopoietic cells. Low expression in nerve cells, hepatocytes, spleen, thymus, small intestine, colon, heart

Stimulates chemotaxis of eosinophils and mast cells

Historically, antihistamines were noted to cause a parallel displacement in the histamine concentration/response. This behavior was consistent with a competitive inhibition for histamine receptors, lending to the classification as the H1 receptor antagonists. With further research, it was found that the antihistamines are in the class that are now called inverse agonists

As an inverse agonist, the compound preferably binds to the inactive state of the histamine receptor, stabilizing the receptor in the inactive conformation, and moves the equilibrium shift in the direction of the inactive state. Since H1 antihistamines have been discovered as inverse agonist, the adoption of the term “H1 antihistamines” has been contemplated [1, 3]. The chemical structure of antihistamines can be varied (Table 22.2).


Table 22.2
Chemical classifications of antihistamines


























Alkylamines

Brompheniramine, chlorpheniramine, dexchlorpheniramine, pheniramine, triprolidine

Ethanolamines

Carbinoxamine, clemastine, dimenhydrinate, diphenhydramine, doxylamine, orphenadrine

Ethylenediamines

Pyrilamine, tripelennamine

Phenothiazines

Methdilazine, promethazine, trimeprazine

Piperidines

Cyproheptadine, fexofenadine, desloratadine, loratadine

Terfenadine and astemizole recalled by FDA

Piperazines

Cetirizine, cyclizine, hydroxyzine, levocetirizine, meclizine


Modified from Nicolas [5]


Indications and Clinical Pearls


H1 antihistamines are used to relieve or prevent allergy symptoms. Suppression of allergic inflammation in the mucous membranes and reduction of the size of wheal (swelling) and flare (vasodilation) response will help alleviate symptoms such as itching, rhinorrhea, sneezing, urticaria, and congestion [4]. The effect on airway smooth muscle is that of bronchodilation. H1 antihistamines can be grouped into two classifications: First-generation (sedative) antihistamines and second-generation (nonsedating) antihistamines. First-generation H1 antihistamines include chlorpheniramine (Chlor-Trimeton), clemastine (Tavist), dexchlorpheniramine (Polaramine), dimenhydrinate (Dramamine), dimetindene (Fenistil), doxylamine (Unisom – used as the sedative in NyQuil), diphenhydramine (Benadryl), hydroxyzine (Vistaril), meclizine (Antivert), orphenadrine (Norflex), pheniramine (Avil), and promethazine (Phenergan).

First-generation H1 antihistamines cross the blood-brain barrier due to their lipophilic molecular structure leading to the possible unwarranted effect of sedation. Adverse reactions may be due to their inhibition on muscarinic, serotonergic, and adrenergic receptors (Table 22.3). Reports of toxicity with overdose, whether intentional or accidental, have been reported.


Table 22.3
H1 antihistamine adverse effects on various receptors






























Adverse effect of first-generation H1 antihistamines

H1 receptor

A310120_1_En_22_Figa_HTML.jpg

CNS neurotransmission reduction, sedation, cognitive and neuropsychomotor performance reduction, appetite↑

Muscarinic receptor

A310120_1_En_22_Figb_HTML.jpg

Tachycardia, urinary retention

α-adrenergic receptor

A310120_1_En_22_Figc_HTML.jpg

Hypotension, dizziness, reflex tachycardia

Serotonin receptor

A310120_1_En_22_Figd_HTML.jpg

Appetite increase

Cardiac channels

A310120_1_En_22_Fige_HTML.jpg

Prolongation of the QT interval, ventricular arrhythmia


Modified from [1, 5]

Antiemetic effects may be elicited due to blockade of the histaminergic signal from the vestibular nucleus to the vomiting center in the medulla [6]. Clinical uses can extend beyond the treatment of allergic symptoms to the treatment of vestibular disorders, sedatives, sleeping aids, and antiemetics. These agents are usually administered in three to four daily doses (Table 22.4).


Table 22.4
First-generation H1 antihistamines






































































































Drug

Treatment usage

Dosage

Special precautions

Special diet

Side effects

Availability

Diphenhydramine Benadryl ©

Allergy symptoms

25–50 mg PO q4–6 h; 10–50 mgIV/IM

(total of 400 mg/day)

(Tabs, capsules, liquid, rapidly dissolving tab or strip, IV)
 
Normal

Dry mouth

Over the counter

Motion sickness

Drowsiness

Insomnia

Dizziness

Dystonia in early Parkinson’s disease

Nausea/vomiting

Constipation

Increase in chest congestion

Headaches photosensitivity

Urinary retention

Hydroxyzine

Vistaril ©

Allergy symptoms

25 mg po TID–QID

25–100 mg IM q 4–6 h

(Capsules, oral suspension, IM)
 
Normal

Dry mouth drowsiness

Prescribed

Nausea/vomiting

Dizziness

Motion sickness

Chest congestion

Anxiety

Headache

Alcohol withdrawal

Muscle weakness

Increased anxiety

Orphenadrine

Norflex ©

Pain (muscle spasms), headache

60–100 mg PO q 8 h, 60 mg PO, IM, IV for Parkinson’s disease

(Tabs, oral solution, IM/IV)
 
Normal

Dry mouth

Prescribed

Migraines

Drowsiness

Parkinson’s disease

Dizziness

Restlessness

Constipation

Increase in chest congestion

Urinary retention

Euphoria

Promethazine

Phenergan ©

Allergy symptoms

6.25–12.5 mg PO qd, 12.5–25 mg IV q 4–6 h (tabs, rectal supp, IV)

Precaution in the elderly and children

Normal

Dry mouth

Prescribed

Motion sickness

Not to be given to children under 2 years of age

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Sep 18, 2016 | Posted by in ANESTHESIA | Comments Off on Histamine Modulators
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