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Safest antihistamines for older adults

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Which antihistamines are safe?Which antihistamines have the highest risk?Other allergy relief medications to avoidDrug interactionsSummary
Antihistamines can help to relieve allergies like hay fever and conjunctivitis. However, they can also cause side effects such as anxiety and confusion in older adults.
Medically reviewed by Philip Ngo, PharmD
Written by Anisha Mansuri
Updated on

Antihistamines are medications that can help relieve allergies such as hives, hay fever, conjunctivitis, and insect bites. They are typically available over-the-counter (OTC). Like with all medications, they can cause side effects like drowsiness, headaches, and nausea.

The chance of these side effects occurring can often increase in older adults. Side effects such as confusion and anxiety may be more likely, and they are often more vulnerable to falls.

Antihistamines may also interact with other medications and worsen conditions such as high blood pressure or kidney damage.

We asked Alyssa Wozniak, PharmD, a clinical assistant professor at D’Youville School of Pharmacy in Buffalo, New York, for her thoughts on allergy medications. She suggests which medications are safe for older adults to take and which ones you should avoid.

What type of antihistamine is typically preferred for older adults?

Person blowing their nose to depict the safest antihistamines for older adults.
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First-generation antihistamines can cross the blood-brain barrier easily and so are more likely to result in side effects. However, second and third-generation antihistamines cannot and so are typically safer.

The American Academy of Allergy, Asthma, and Immunology (AAAAI) recommends second and third-generation antihistamines as the safest option for older adults, as they cause fewer side effects. They include loratadine (Claritin) and fexofenadine (Allegra).

“They’re effective for symptoms such as itching, sneezing, and a runny nose,” says Wozniak.

Antihistamine prescription nasal sprays can also be good options. This is because nasal sprays typically aren’t absorbed as much as oral antihistamines and may have fewer side effects. Examples include azelastine (Astelin) and olopatadine (Patanase). Olopatadine is also available in the form of eye drops, which can help manage itchy and watery eyes.

Several other options are available, such as intranasal corticosteroids, which are sprayed or inhaled into the nose to help with allergy symptoms. Examples include fluticasone (Flonase) and budesonide (Rhinocort). They are effective and safe, especially for people with nasal congestion who don’t respond well to oral antihistamines.

The most common side effect of nasal sprays is minor nosebleeds. If you blow your nose, you might see a little bit of blood. There are some rare reports that long-term use may lead to glaucoma. If you are concerned that you may have glaucoma after using nasal sprays for a period of time, consider speaking with a doctor. They can decide if you would benefit from a lower dose.

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Which antihistamines carry the highest risk for older adults?

First-generation oral antihistamines tend to carry the highest chance of complications for older adults and should be avoided. Common examples include diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton).

The complications of first-generation antihistamines could be severe for older adults as they can cause anticholinergic effects, which block the action of neurotransmitters in the brain. The symptoms can include:

However, many of these side effects are unlikely to occur when using these medications as a topical cream. This is because the cream acts locally, which means any side effects that do occur would not be widespread.

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Which other allergy relief medications should be avoided?

All drugs can carry side effects. Unfortunately, older adults can be more susceptible to medications because of the natural changes that happen in the body with aging. Your liver and kidneys can’t flush out medications as well, so drugs stay in the system longer.

Alongside first-generation antihistamines, other allergy relief medications, like decongestants, can increase the chance of complications in older adults.

Decongestants, such as pseudoephedrine (Sudafed), “can carry a high risk for older adults, especially those with high blood pressure,” says Wozniak.

“Sudafed can affect your heart rate. That’s why it’s not recommended for people with heart disease or abnormal heart rhythm,” mentions Wozniak. It can also cause urinary retention, so it should be avoided by people with an enlarged prostate.

Some allergy medications can also be combined with decongestants, which is why it’s always important to read the label of your medication first.

Which medications don’t mix well with allergy medications?

Some medications can have similar side effects to antihistamines and shouldn’t be taken together, as they can increase complications and may lead to heavy sedation. These include:

  • tricyclic antidepressants
  • seizure medications
  • sleeping pills
  • painkillers
  • tranquilizers and other sedatives
  • antidepressants, such as MAOIs (monoamine oxidase inhibitors)

Medications for an overactive bladder (OAB) also do not mix well. If you’re taking allergy relief medications on top of your OAB medication, it could also cause too much urine retention and may lead to urinary tract infections (UTIs).

This is why it’s always important to let a healthcare professional know what medications you are taking, whether it is prescription, OTC, or herbal treatments. They will be able to check for any drug interactions.

If you have cognitive conditions, such as mild dementia or Alzheimer’s, “you’ll want to stay away from those first-generation antihistamines for sure,” says Wozniak.

“We would worry about worsening that situation. In this case, try to choose remedies that have local and not body-wide effects. For example, choose eye drops and nasal sprays over pills,” suggests Wozniak.


As there are so many allergy relief options available OTC, it can be hard to keep track of what’s old and what’s new. Speaking with a healthcare professional can help.

They can take into account your medical history and any other medications you take to identify the allergy treatment options that are the safest and most effective option for your individual needs.

Download the free Optum Perks Discount Card to save up to 80% on some prescription medications.

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