Abstract
Despite a lack of evidence of benefit, the compounded product ABH gel (lorazepam,
diphenhydramine, and haloperidol) continues to be prescribed for individuals in hospice
and palliative care settings for the treatment of nausea and vomiting and terminal
delirium. More effective and reliable pharmacological and nonpharmacological strategies
exist for the treatment of these conditions in the palliative care and hospice settings.
We discuss the pharmacokinetic and clinical evidence for the individual components
of ABH gel, as well as the compounded product, and attempt to understand the mechanism
of effect that some purport to see, as well as why the compound continues to enjoy
such a cult following. Truly, the continued use of ABH gel makes for a pricey placebo
and delays the treatment of end-of-life symptoms with modalities that work.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Five things physicians and patients should question in hospice and palliative medicine.J Pain Symptom Manage. 2013; 45: 595-605
- ABH gel is not absorbed from the skin of normal volunteers.J Pain Symptom Manage. 2012; 43: 961-966
- ABHR gel in the treatment of nausea and vomiting in the hospice patient.Int J Pharm Compd. 2006; 10: 95-98
- Tolerability of the compound ABHR in hospice patients.J Palliat Med. 2005; 8: 1135-1143
- Lorazepam, diphenhydramine, and haloperidol transdermal gel for rescue from chemotherapy-induced nausea/vomiting: Results of two pilot trials.J Support Oncol. 2008; 6: 27-32
- A randomized trial of the effectiveness of topical “ABH Gel” (Ativan®, Benadryl®, Haldol®) vs. placebo in cancer patients with nausea.J Pain Symptom Manage. 2014; 48: 797-803
- 〈795〉 Pharmaceutical Compounding—Nonsterile Preparations. Revised Bulletin. The United States Pharmacopeial Convention, United States Pharmacopeia; Rockville, Maryland. 2014
- Nausea and vomiting in hospice patients.Int J Pharm Compd. 2000; 4: 250-251
- Are newer, more expensive pharmacotherapy options associated with superior symptom control compared to less costly agents used in a collaborative practice setting?.Am J Hosp Palliat Care. 2006; 23: 135-149
- Lexicomp Online, Lexi-Drugs Online, July 20, 2020. UpToDate, Inc., Hudson, OH2020
- Benzodiazepine use in older adults: Dangers, management, and alternative therapies.Mayo Clin Proc. 2016; 91: 1632-1639
- American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.J Am Geriatr Soc. 2019; 67: 674-694
- Benzodiazepine use and hip fractures in the elderly: Who is at greatest risk?.Arch Intern Med. 2004; 164: 1567-1572
- Meta-analysis of the impact of 9 medications classes on falls in elderly persons.Arch Intern Med. 2009; 169: 1952-1960
- Benzodiazepines and risk of death: Results from two large cohort studies in France and UK.Eur Neuropsychopharmacol. 2015; 25: 1566-1577
- Histamine-1 receptor antagonism for treatment of insomnia.J Am Pharm Assoc. 2012; 52: e210-e219
- Review of safety and efficacy of sleep medicines in older adults.Clin Ther. 2016; 38: 2340-2372
- The anticholinergic risk scale and anticholinergic adverse effects in older persons.Arch Intern Med. 2008; 168: 508-513
- Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients.Arch Intern Med. 2001; 161: 2091-2097
- Diphenhydramine: Pharmacokinetics and pharmacodynamics in elderly adults, young adults, and children.J Clin Pharmacol. 1990; 30: 665-671
- Death of a child from topical diphenhydramine.Am J Forensic Med Pathol. 2009; 30: 380-381
- Diphenhydramine toxicity in three children with varicella-zoster infection.DICP. 1991; 25: 130-132
- Topically induced diphenhydramine toxicity.J Emerg Med. 1990; 8: 59-61
- Topical diphenhydramine toxicity in a five year old with varicella.Pediatr Emerg Care. 1988; 4: 18-20
- An evidence-based review of the efficacy of topical antihistamines in the relief of pruritis.J Drugs Dermatol. 2010; 9: 992-997
- Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: A randomized clinical trial.JAMA Intern Med. 2017; 177: 34-42
- SMGA gels for the skin permeation of haloperidol.J Controlled Rel. 2005; 106: 88-98
- Massage and touch for dementia.Cochrane Database Syst Rev. 2006; 2006: CD004989
- The effect of massage on agitated behaviours in older people with dementia: A literature review.J Clin Nurs. 2013; 22: 601-610
- Massage in the management of agitation in nursing home residents with cognitive impairment.Geriatr Nurs. 2009; 30: 108-117
- Review of acupressure studies for chemotherapy-induced nausea and vomiting control.J Pain Symptom Manage. 2008; 36: 529e544
- Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting.Cochrane Database Syst Rev. 2009; : CD003281
- The IAHPC Manual of Palliative Care.3rd ed. IAHPC Press, Houston, TX2013
- Management of intractable nausea and vomiting in patients at the end of life: “I was feeling nauseous all of the time… nothing was working”.JAMA. 2007; 298: 1196-1207
- End-of-life care: Managing common symptoms.Am Fam Physician. 2017; 95: 356-361
- Olanzapine in the treatment of refractory nausea and vomiting in palliative care settings.Indian J Palliat Care. 2018; 24: 372-374
- Olanzapine for intractable nausea in palliative care patients.J Palliat Med. 2003; 6: 251-255
- Chronic nausea and anorexia in advanced cancer patients: A possible role for autonomic dysfunction.J Pain Symptom Manage. 1987; 2: 19-21
- The effects of potent analgesics upon vestibular function.J Clin Invest. 1952; 31: 259-266
- Delirium and agitation at the end of life.BMJ. 2016; 353: i3085
- Clinical assessment and management of delirium in the palliative care setting.Drugs. 2017; 77: 1623-1643
- Management of delirium in palliative care: A review.Curr Psychiatry Rep. 2015; 17: 550
- Drug therapy for delirium in terminally ill adult patients.Cochrane Database Syst Rev. 2012; 11: CD004770
- Effect of lorazepam with haloperidol vs haloperidol alone on agitated delirium in patients with advanced cancer receiving palliative care: A randomized clinical trial.JAMA. 2017; 318: 1047-1056
Article info
Publication history
Published online: November 24, 2020
Footnotes
The authors declare no conflicts of interest.
Identification
Copyright
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
