CME Review Article

New Oral Antihistamines in Pediatrics

Russ Horowitz, MD,* and Sally Reynolds, MDy

Key Words: histamine, allergic rhinitis, atopic dermatitis, urticaria

TARGET AUDIENCE
This CME activity is intended for physicians, medical
students, nurse practitioners, and physician assistants who
manage children with acute illness in either the emergency
department (ED) or office-based settings. Pediatric emergency physicians, emergency physicians, pediatricians, and family practitioners will find this information especially useful.

LEARNING OBJECTIVES
After completion of the article, the reader should be
able to:
1. Discuss the role histamine plays in allergic responses.
2. Describe differences between first- and second-generation
antihistamines based on pharmacology and side effect
profiles.
3. Identify the second-generation antihistamines and their
relative strengths and weaknesses.

ntihistamines have been used for almost 60 years to

reduce the pruritus, edema, rhinorrhea, and irritation of
allergies. The second-generation antihistamines began to
appear in the mid-1980s. They were engineered to maximize
the benefits of the first-generation of medications while
minimizing sedative side effects.

*Fellow, Pediatric Emergency Medicine, Feinberg School of Medicine,

Northwestern University; and yAssociate Professor of Pediatrics,
Feinberg School of Medicine, Northwestern University, Chicago Illinois.
Dr. Horowitz and Dr. Reynolds have disclosed that they have no significant
relationship with or financial interests in any commercial companies that
pertain to this educational activity.
Address correspondence and reprint requests to Sally Reynolds, MD,
Northwestern University Medical School, CMH ED, 2300 Childrens
Plaza Box 62, Chicago IL 60614.
Copyright n 2004 by Lippincott Williams & Wilkins
ISSN: 0749-5161/04/2002-0143

PHARMACOLOGY AND PATHOPHYSIOLOGY

The first-generation H1 antagonists include diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton),
hydroxyzine (Atarax), and promethazine (Phenergan). They
are all small, lipophilic molecules and therefore easily cross
through the blood brain barrier. These pharmacologic
qualities are also responsible for their sedative properties. In
addition, these agents also bind muscarinic receptors, which
produce the unpleasant anticholinergic side effects such as dry
mouth, dry eyes, blurry vision, and agitation. The secondgeneration H1 antagonists including cetirizine (Zyrtec), loratidine (Claritin), fexofenadine (Allegra), and desloratidine
(Clarinex) are much larger molecules, have a different ionic
wcharge, and are highly lipophobic. These features reduce
their passage into the CNS and limit their central effects.
Members of each generation are listed in Table 1.
H1 receptors are located on airway smooth muscle,1
2
brain, vascular smooth muscle,3 gastrointestinal tract,4 endothelial cells,5 monocytes, macrophages, and lymphocytes.6,7
In the early phase response, binding of the allergen triggers the
release of histamine and other regulatory molecules from
cytoplasmic granules of mast cells and basophils. The binding of histamine at various sites is responsible for the
symptoms commonly associated with an allergic reaction
such as vasodilatation, bronchoconstriction, mucus hypersecretion, wheal and flare.8,9 Four to 8 hours later, the late phase
response occurs and cytokines cause the release of inflammatory mediators.10 Because antihistamines are competitive
antagonists, they are more effective at inhibiting versus
reversing histaminic effects. Therefore, maximal effect is obtained when the drugs are used prophylactically.11
H2 receptors are present on gastric mucosa, brain,12
lymphoid, and inflammatory cells.13 Histamine binding at
gastric sites induces acid secretion.14 Histamine acts as a
neurotransmitter when bound at the H3 sites in the brain and
regulates its own production and release. In addition, binding
to bronchial smooth muscle may help modulate allergic
airway responses.15

SIDE EFFECTS OF ANTIHISTAMINES

Although the first-generation H1 antagonists are very
effective, their benefits are often limited by central side

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143

Pediatric Emergency Care  Volume 20, Number 2, February 2004

Horowitz and Reynolds

effects. Young children may suffer from either sedation or a

paradoxical agitation.16 Older children and adults usually
experience fatigue and decreased attention, which may interfere with cognitive, motor, and intellectual performance.17
These effects are significant enough to pose a risk to
the user as evidenced by a Canadian study of fatal automobile crashes. In this epidemiologic investigation, drivers
who were determined to be at fault were 1.5 times more
likely to have used a sedating antihistamine than drivers
not deemed responsible for the crash.18 In a study of
childhood school performance by Vuurman et al,19 diphenhydramine was shown to produce significantly more
learning impairment as compared to loratidine, a secondgeneration antihistamine.
Two of the second-generation antihistamines to first
become available in the United States were terfenadine
(Seldane) and astemizole (Hismanal). Evidence of cardiotoxicity, particularly torsade de pointes and QT interval prolongation, was realized and these two medications were
eventually withdrawn from the US market in the 1990s. These
side effects are more pronounced when terfenadine (Seldane)
and astemizole (Hismanal) are used in conjunction with
macrolide antibiotics20 and certain antifungal agents21,22 but
also occur when they are used alone.20,2325 The etiology of
the cardiotoxicity arises from interferences which flow
through a potassium ion channel.26
Although a small number of case reports have shown
prolongation of the QT interval and arrhythmias with the
use of second-generation antihistamines,2730 they have all
been used in adults with underlying cardiac pathology.
Cardiotoxicity does not appear to represent an inherent
characteristic of the newer antihistamines,3133 however,
further study is indicated to determine the true frequency of
these effects.

As a result of their selective engineering, the secondgeneration antihistamines do not bind muscarinic receptors
and therefore do not have anticholinergic side effects. Most
are not active on serotonergic receptors and do not affect
appetite or cause weight gain.33 Few case reports of
ingestions of the newer antihistamines exist in children.
As a result, there are no good guidelines directing management of pediatric poisonings from these agents. One high
dose loratidine (Claritin) exposure in a 6-year-old resulted
in minor hypertension and tachycardia which was managed with supportive measures alone.34 Three other reports
have documented overdoses of cetirizine (Zyrtec). No
cardiovascular effects were noted and patients experienced only sedation35,36 and, in one case, agitation.37 All
children underwent conservative management and suffered
no sequelae.

SPECIFIC AGENTS
Cetirizine (Zyrtec)
Although cetirizine (Zyrtec) is a second-generation
antihistamine, it retains some of the sedative side effects of
its parent compound, hydroxyzine (Atarax). The drug is not
metabolized by the liver, which may explain its rapid onset
of activity and lack of interaction with many other medications.38,39 Cetirizine (Zyrtec) has been found to be among the
most effective antihistamines in preventing allergic skin
reactions.40 42 It has, by far, the most documented antiallergic effects independent of its antihistaminic effects at
approved dosages.43 It has been shown to decrease eosinophilic infiltration of the skin44,45 and diminish the late phase
response.44 46 It is approved for use by children as young as
6 months old.

Loratidine (Claritin)
TABLE 1. Characteristics of First- and Second-Generation
Antihistamines
Generic Name

Trade Name

First-generation
Antihistamines
Diphenhydramine
Clemastine
Chlorpheniramine
Hydroxyzine
Promethazine
Second-generation
Antihistamines
Loratidine
Certizirine
Fexofenadine
Desloratidine

144

Half-life (hours)

Benadryl
Tavist
Chlor-Trimeton
Atarax
Phenergan

Claritin
Zyrtec
Allegra
Clarinex

Loratidine (Claritin) is the only member of the secondgeneration antihistamines to be approved for over the counter
use. It is metabolized by the cytochrome P450 system47 to
descarboethoxyloratidine. Loratidine (Claritin) has a slightly slower onset of action compared with other secondgeneration antihistamines.39,48,49

Fexofenadine (Allegra)

7.511
710
1115
2530

Fexofenadine (Allegra) is the long-acting, nonsedating,

active metabolite of terfenadine. It is not metabolized by the
liver and therefore its activity is not affected by medications
that are processed by the P450 system.50 Although it is
approved for use by children as young as 6 years old, it is not
available in liquid form.

Desloratidine (Clarinex)
Desloratidine (Clarinex), the primary active metabolite
of loratidine (Claritin), recently gained FDA approval in 2001.
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Pediatric Emergency Care  Volume 20, Number 2, February 2004

New Oral Antihistamines in Pediatrics

TABLE 2. Features of Second-Generation Antihistamines

Name

Indications

Forms

Cetirizine

SAR, PAR, CU

Tabs: 5, 10 mg
Syrup: 5 mg/5 cc

Loratidine

SAR, PAR, U

Fexofenadine

SAR, CIU

Tabs/reditabs: 10 mg
Syrup: 5 mg/5 cc
Tabs: 30, 60, 180 mg

Desloratidine

SAR, PAR, CIU

Tabs/reditabs: 5 mg

Dosage

Cost

>12 years: 10 mg qd
611 years: 5 mg qd
6 months to 5 years: 2.5 mg qd
>6 years: 10 mg qd
26 years: 5 mg qd
>12 years: 60 mg bid or 180 mg qd
611 years: 30 mg bid
>12 years: 5 mg qd

$57.53
$52.95
$31.00
$32.97/$38.97
$13.75
$61.74/$62.03
$38.99
$68.49

CIU indicates chronic idiopathic urticaria; CU, chronic urticaria; PAR, perennial allergic rhinitis; SAR, seasonal allergic rhinitis; U, urticaria.

It is the only nonsedating antihistamine that is approved for

3 indications (seasonal allergic rhinitis, perennial allergic
rhinitis, and urticaria). It is not processed by the hepatic P450
system and therefore has little possibility of clinically
significant drug interactions.51

INDICATIONS
Allergic Rhinitis
Allergic rhinitis affects up to 30% of adolescents52 and
is responsible for over 2 million missed school days each
year.53 It can be differentiated into 2 categories based on the
duration and timing of symptoms. Seasonal allergic rhinitis
(SAR), commonly known as hay fever, is triggered by weed,
grass, and tree pollens, whereas perennial allergic rhinitis
(PAR) is present year round.54 Second-generation antihistamines have proven to be potent and safe in controlling
allergic rhinitis symptoms such as watery eyes, nasal pruritis,
and rhinorrhea 32,5456 even in preschool children.57 Multiple
studies have shown the combination of newer antihistamines
and pseudoephedrine to be more effective than either
component alone in alleviating nasal congestion associated
with allergic rhinitis.54,58,59

Atopic Dermatitis and Urticaria

Much of the effectiveness of antihistamines in the management of urticaria and atopic dermatitis has been attributed
to their sedative effects.60 However, many studies have shown
nonsedating second-generation antihistamines to be very
useful in controlling symptoms of urticaria and atopic
dermatitis. Benefits included reduction of pruritus, decreased
lichenification, erythema, and lesion size.4042,49,61,62
Although there is no proven cause and effect relationship between atopic dermatitis and asthma, development of
the former often predates that of the latter.63 The severity of
atopic dermatitis has been correlated to asthmatic symptoms.64 The Early Treatment of the Atopic Child (ETAC)
Study Group was designed to evaluate whether cetirizine

(Zyrtec) could prevent young children (12 years old) with

atopic dermatitis from developing asthma. Patients in this
double-blinded randomized trial received medication for 18
months and were followed for a subsequent 18 months after
discontinuation of treatment. Infants with sensitivity to house
mites, grass pollen, or both, who received cetirizine (Zyrtec),
were significantly less likely to develop asthma as compared
to those treated with placebo.65
The second-generation antihistamines have proven
safe and effective in controlling rhinitis and urticaria in
children. They have all but replaced their predecessors
because of improved side effect profiles with significantly
less sedation. Long-term studies have validated their safety
and efficacy in even preschool children. In addition to their
antihistaminic properties, some of these newer agents may
possess potent antiallergic properties (Table 2).
REFERENCES
1. Casale TB, Rodbard D, Kaliner M. Characterization of histamine H-1
receptors on human peripheral lung. Biochem Pharmacol. 1985;34(18):
32853292.
2. Hill SJ, Emson PC, Young JM. The binding of [3H]mepyramine to
histamine H1 receptors in guinea-pig brain. J Neurochem. 1978;31(4):
9971004.
3. Hide M, et al. Histamine H1-receptor in endothelial and smooth muscle
cells of guinea-pig aorta. Eur J Pharmacol. 1988;148(2):161169.
4. Hill SJ, Young YM. Characterization of [3H]mepyramine binding to the
longitudinal muscle of guinea pig small intestine. Mol Pharmacol. 1981;
19(3):379387.
5. Jeannin P, et al. Histamine induces interleukin-8 secretion by endothelial
cells. Blood. 1994;84(7):22292233.
6. Cameron W, Doyle K, Rocklin RE. Histamine type I (H1) receptor
radioligand binding studies on normal T cell subsets, B cells, and
monocytes. J Immunol. 1986;136(6):21162120.
7. Villemain FM, Bach JF, Chatenoud LM. Characterization of histamine
H1 binding sites on human T lymphocytes by means of 125Iiodobolpyramine. Preferential expression of H1 receptors on CD8 T
lymphocytes. J Immunol. 1990;144(4):14491454.
8. White MV. The role of histamine in allergic diseases. J Allergy Clin
Immunol. 1990;86(4 Pt 2):599605.
9. White MV, Slater JE, Kaliner MA. Histamine and asthma. Am Rev
Respir Dis. 1987;135(5):11651176.
10. Limon L, Kockler DR. Desloratadine: a nonsedating antihistamine. Ann
Pharmacother. 2003;37(2):237246;quiz 313316.

n 2004 Lippincott Williams & Wilkins

Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

145

Horowitz and Reynolds

Pediatric Emergency Care  Volume 20, Number 2, February 2004

11. Katcher ML. Cold, cough, and allergy medications: uses and abuses.
Pediatr Rev. 1996;17(1):1217.
12. Larsen JS. Do antihistamines have a role in asthma therapy? Pharmacotherapy. 2001;21(3 Pt 2):28S33S.
13. Ash AS, Schild HO. Receptors mediating some actions of histamine.
Br J Pharmacol. 1966;27(2):427 439.
14. Black JW, et al. Definition and antagonism of histamine H2-receptors.
Nature. 1972;236(5347):385390.
15. Arrang JM. Pharmacological properties of histamine receptor subtypes.
Cell Mol Biol (Noisy-le-grand). 1994;40(3):275281.
16. Simons FE, Simons KJ. The pharmacology and use of H1-receptorantagonist drugs. N Engl J Med. 1994;330(23):16631670.
17. Roth T, et al. Sedative effects of antihistamines. J Allergy Clin Immunol.
1987;80(1):9498.
18. Warren RA, et al. Analysis of fatal traffic crashes in Canada, 1977
1978: focus: the impaired driver. TIRF reports. 1980, Ottawa: Traffic
Injury Research Foundation of Canada. iv, 13.
19. Vuurman EF, et al. Seasonal allergic rhinitis and antihistamine effects
on childrens learning. Ann Allergy. 1993;71(2):121126.
20. Woosley RL. Cardiac actions of antihistamines. Annu Rev Pharmacol
Toxicol. 1996;36:233252.
21. Tsai WC, Tsai LM, Chen JH. Combined use of astemizole and ketoconazole resulting in torsade de pointes. J Formos Med Assoc. 1997;
96(2):144146.
22. Honig PK, et al. Terfenadine-ketoconazole interaction. Pharmacokinetic
and electrocardiographic consequences. JAMA. 1993;269(12):15131518.
23. Craft TM. Torsade de pointes after astemizole overdose. Br Med J
(Clin Res Ed). 1986;(6521):660.
24. Snook J, et al. Torsade de pointes ventricular tachycardia associated
with astemizole overdose. Br J Clin Pract. 1988;42(6):257259.
25. Goss JE, Ramo BW, Blake K. Torsades de pointes associated with
astemizole (Hismanal) therapy. Arch Intern Med. 1993;153(23):2705.
26. Suessbrich H, et al. Blockade of HERG channels expressed in Xenopus
oocytes by the histamine receptor antagonists terfenadine and astemizole. FEBS Lett. 1996;385(12):7780.
27. Lindquist M, Edwards IR. Risks of non-sedating antihistamines. Lancet.
1997;349(9061):1322.
28. Atar S, et al. Torsades de pointes and QT prolongation due to a combination of loratadine and amiodarone. Pacing Clin Electrophysiol.
2003;26(3):785786.
29. Kuchar DL, Walker BD, Thorburn CW. Ventricular tachycardia following ingestion of a commonly used antihistamine. Med J Aust. 2002;
176(9):429430.
30. Pinto YM, et al. QT lengthening and life-threatening arrhythmias associated with fexofenadine. Lancet. 1999;353(9157):980.
31. DuBuske LM. Second-generation antihistamines: the risk of ventricular
arrhythmias. Clin Ther. 1999;21(2):281295.
32. Wahn U, et al. Fexofenadine is efficacious and safe in children (aged
611 years) with seasonal allergic rhinitis. J Allergy Clin Immunol.
2003;111(4):763769.
33. Simons FE. H1-recepor antagonists: safety issues. Ann Allergy Asthma
Immunol. 1999;83:481 488.
34. Cobb DB, Watson WA, Fernandez MC. High-dose loratadine exposure
in a six-year-old child. Vet Hum Toxicol. 2001;43(3):163164.
35. Spiller HA, et al. Retrospective evaluation of cetirizine (zyrtec) ingestion. J Toxicol Clin Toxicol. 2002;40(4):525526.
36. Hansen JJ, Feilberg NH Feilberg Jorgensen. [Accidental cetirizine poisoning in a four-year-old boy]. Ugeskr Laeger. 1998;160(41):59465947.
37. Ridout SM, Tariq SM. Cetirizine overdose in a young child. J Allergy
Clin Immunol. 1997;99(6 Pt 1):860861.
38. Frossard N, et al. Nasal effect of cetirizine and loratadine at 24 hours in
patients with allergic rhinitis. Am J Ther. 1998;5(5):307311.
39. Frossard N, et al. Onset of action in the nasal antihistaminic effect of
cetirizine and loratadine in patients with allergic rhinitis. Allergy. 1997;
52(2):205209.
40. Simons FE, Johnston L, Simons KJ. Clinical pharmacology of the H1receptor antagonists cetirizine and loratadine in children. Pediatr Allergy Immunol. 2000;11(2):116119.
41. Grant JA, et al. A double-blind, single-dose, crossover comparison of
cetirizine, ebastine, epinastine, fexofenadine, terfenadine, and loratadine

146

42.

43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.

58.

59.
60.
61.
62.
63.
64.
65.

versus placebo: suppression of histamine-induced wheal and flare response for 24 h in healthy male subjects. Allergy. 1999;54(7):700707.
Simons FE, McMillan JL, Simons KJ. A double-blind, single-dose,
crossover comparison of cetirizine, terfenadine, loratadine, astemizole,
and chlorpheniramine versus placebo: suppressive effects on histamineinduced wheals and flares during 24 hours in normal subjects. J Allergy
Clin Immunol. 1990;86(4 Pt 1):540547.
Walsh GM. The effects of cetirizine on the function of inflammatory
cells involved in the allergic response. Clin Exp Allergy. 1997;27
(suppl 2):4753; discussion 5456.
Fadel R, et al. In vivo effects of cetirizine on cutaneous reactivity and
eosinophil migration induced by platelet-activating factor (PAF-acether)
in man. J Allergy Clin Immunol. 1990;86(3 Pt 1):314320.
Fadel R, et al. Inhibitory effect of cetirizine 2HCl on eosinophil migration in vivo. Clin Allergy. 1987;17(4):373379.
Charlesworth EN, et al. Effect of H1 receptor blockade on the early and
late response to cutaneous allergen challenge. J Pharmacol Exp Ther.
1992;262(3):964970.
Greaves MW. Antihistamines. Dermatol Clin. 2001;19(1):5362.
Bayramgurler D, et al. Effects of acrivastine, loratadine and cetirizine
on histamine-induced wheal and flare responses. Clin Exp Dermatol.
1999;24(5):407 411.
Doherty V, et al. Treatment of itching in atopic eczema with antihistamines with a low sedative profile. BMJ. 1989;298(6666):96.
Markham A, Wagstaff AJ. Fexofenadine. Drugs. 1998;55(2):269274;
discussion 275276.
Barecki ME, et al. In vitro characterization of the inhibition profile of
loratadine, desloratadine, and 3-OH-desloratadine for five human cytochrome P-450 enzymes. Drug Metab Dispos. 2001;29(9):11731175.
Tarnasky PR, Van Arsdel PP Jr. Antihistamine therapy in allergic
rhinitis. J Fam Pract. 1990;30(1):7180.
Storms WW. Treatment of allergic rhinitis: effects of allergic rhinitis
and antihistamines on performance. Allergy Asthma Proc. 1997;18(2):
5961.
Sussman GL, et al. The efficacy and safety of fexofenadine HCl and
pseudoephedrine, alone and in combination, in seasonal allergic rhinitis.
J Allergy Clin Immunol. 1999;104(1):100106.
Gillman SA, et al. The health-related quality of life effects of once-daily
cetirizine HCl syrup in children with seasonal allergic rhinitis. Clin
Pediatr (Phila). 2002;41(9):687696.
Grant JA, et al. Cetirizine in patients with seasonal rhinitis and concomitant asthma: prospective, randomized, placebo-controlled trial.
J Allergy Clin Immunol. 1995;95(5 Pt 1):923932.
Yang YH, et al. A double-blind, placebo-controlled, and randomized
study of loratadine (Clarityne) syrup for the treatment of allergic rhinitis
in children aged 3 to 12 years. Asian Pac J Allergy Immunol. 2001;
19(3):171175.
Bronsky E, et al. Comparative efficacy and safety of a once-daily
loratadine-pseudoephedrine combination versus its components alone
and placebo in the management of seasonal allergic rhinitis. J Allergy
Clin Immunol. 1995;96(2):139147.
Bertrand B, et al. Cetirizine and pseudoephedrine retard alone and in
combination in the treatment of perennial allergic rhinitis: a doubleblind multicentre study. Rhinology. 1996;34(2):9196.
Krause L, Shuster S. Mechanism of action of antipruritic drugs. Br Med
J (Clin Res Ed). 1983;287(6400):11991200.
Finn AF Jr, et al. A double-blind, placebo-controlled trial of fexofenadine HCl in the treatment of chronic idiopathic urticaria. J Allergy
Clin Immunol. 1999;104(5):10711078.
Nelson HS, Reynolds R, Mason J. Fexofenadine HCl is safe and effective for treatment of chronic idiopathic urticaria. Ann Allergy Asthma
Immunol. 2000;84(5):517522.
Leung DY. Atopic dermatitis: new insights and opportunities for therapeutic intervention. J Allergy Clin Immunol. 2000;105(5):860876.
Brinkman L, et al. Bronchial and skin reactivity in asthmatic patients with
and without atopic dermatitis. Eur Respir J. 1997;10(5):10331040.
Warner JO. A double-blinded, randomized, placebo-controlled trial of
cetirizine in preventing the onset of asthma in children with atopic
dermatitis: 18 months treatment and 18 months posttreatment followup. J Allergy Clin Immunol. 2001;108(6):929937.

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New Oral Antihistamines in Pediatrics

CME EXAM
Instructions for the Pediatric Emergency Care CME Program Examination
To earn CME credit, you must read the designated article and complete the examination below, answering at least 80%
of the questions correctly. Mail a photocopy of the completed answer sheet to the Office of Continuing Education, Wolters
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CME EXAMINATION
February 2004
Please mark your answers on the ANSWER SHEET.
New Oral Antihistamines in Pediatrics, Horowitz and Reynolds
1. Which is the only non sedating antihistamine to be
approved for three indications?
a) cetirizine
b) hydroxyzine
c) loratidine
d) fexofenadine
e) desloratidine
2. As compared to the first generation antihistamines, the
second generation:
a) cross the blood brain barrier more easily
b) are all only available by prescription
c) are larger and highly lipophobic molecules
d) should not be used with antifungal agents
e) bind muscarinic receptors
3. The cheapest second-generation antihistamine is:
a) Certirizine
b) Loratidine

c) Desloratidine
d) Fexotendadine
4. A study suggests that early treatment of an atopic child
with which antihistamine may prevent asthma:
a) Certirizine
b) Loratidine
c) Diphenhydramine
5. Which second-generation antihistamine is approved for
use in children as young as 6 months old:
a) Cetirizine
b) Fexofenadine
c) Loratidine

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Pediatric Emergency Care  Volume 20, Number 2, February 2004

Horowitz and Reynolds

ANSWER SHEET FOR THE PEDIATRIC EMERGENCY CARE

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February 2004
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information:
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1.

A B C D E

2.
3.
4.

A B C D E
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5.

A B C D E

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[]5
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