Use of diphenhydramine as an adjunctive sedative for colonoscopy in patients on chronic opioid therapy: a randomized controlled trial

  • Salman Nusrat
    Correspondence
    Reprint requests: Salman Nusrat, MD, Director, Neurogastroenterology and Motility Program, Assistant Professor of Medicine, University of Oklahoma Health Sciences Center, Division of Digestive Diseases and Nutrition, Andrews Academic Tower, Suite 7400, 800 Stanton L. Young Boulevard, Oklahoma City, OK 73104.
    Affiliations
    Department of Medicine, Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Department of Medicine, Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • Mohammed F. Madhoun
    Affiliations
    Department of Medicine, Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Department of Medicine, Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • William M. Tierney
    Affiliations
    Department of Medicine, Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Department of Medicine, Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
    Search for articles by this author
Published:April 21, 2018DOI:https://doi.org/10.1016/j.gie.2018.04.2342

      Background and Aims

      Chronic opioid use increases tolerance to sedatives. Diphenhydramine is recommended for difficult-to-sedate patients during endoscopic procedures. We hypothesized that the addition of diphenhydramine to midazolam and fentanyl would improve objective and subjective measures of procedural sedation.

      Methods

      This randomized, double-blind, placebo-controlled trial included patients on chronic opioids undergoing colonoscopy. Patients were randomized to receive 50 mg of diphenhydramine intravenously (n = 61) or placebo (n = 58), in addition to fentanyl and midazolam. Baseline characteristics, amount of fentanyl and midazolam, procedure times, and adverse events were recorded. Quality of sedation was assessed by the physician and nurse. Patients rated pain and amnesia on a 10-point scale.

      Results

      There was no difference in amounts of fentanyl (125.4 ± 56.2 μg vs 126.9 ± 53.5 μg, P = .88) and midazolam (4.9 ± 2.1 mg vs 5 ± 1.9 mg, P = .79) used. The mean sedation scores from the physician (6.2 ± 1.1 vs 5.3 ± 1.2, P =.0002) and nurses (5.6 ± 1.5 vs 5.1 ± 1.4, P =.04) were statistically significant in favor of the diphenhydramine arm. Patient scores for pain (2.05 ± 2.17 vs 3.09 ± 3.95, P =.047) and amnesia (7.8 ± 3.4 vs 6.5 ± 3.8, P =.047) favored the group that received diphenhydramine. Qualitative assessment showed no significant difference between the groups. There was no difference in induction time (P = .86), procedure duration (P = .98), or recovery time (P = .16). Hypotensive episodes were more common in the placebo group (P = .027).

      Conclusions

      In patients on chronic opioid therapy, administration of diphenhydramine does not allow for lower doses of procedural sedatives but improves quality of sedation without increasing the number of adverse events. (Clinical trial registration number: NCT T01967433.)

      Abbreviations:

      IQR (interquartile range), SD (standard deviation), VAMC (Veterans’ Affairs Medical Center)
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