Diphenhydramine as an Adjunctive Sedative in Patients on Chronic Opioids

Study Overview
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Brief Summary
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To access the efficacy of adding diphenhydramine as adjunct to improve sedation and to reduce the amount of standard sedatives used during colonoscopy in patients on chronic opioids.

Detailed Description
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Specific Aims: The primary aim of our study is to determine if addition of Diphenhydramine to Fentanyl and Midazolam will decrease the dose of Fentanyl and Midazolam used during colonoscopy in individuals on chronic opioids. Secondarily we will be looking at quality of sedation, duration of colonoscopy, time to reach cecum and adverse effects (hypoxia defined as O2 saturation less than 89% lasting for more than 30 seconds, hypotension defined as systolic BP less than 90 mmhg and use of reversal agents i.e Naloxone or Flumazenil). Day of Procedure: After consent is obtained the medical records of the patients will be reviewed and demographic information, co-morbidities, current medication will be extracted and recorded. On the day of colonoscopy Alcohol use disorder inventory (AUDIT) will be used to screen for alcohol abuse. AUDIT was developed by World Health Organization and has been validated over a period of 2 decades. It consist of 10 questions, each question is scored 0-4 on the basis of subjects alcohol use. It takes about 2-4 minutes to complete. A score 10 or greater is highly specific or alcohol use. Subjects will be checked in and prepared according to routine protocols of the VA medical center. Participants will be randomly assigned to receive either 50 mg of diphenhydramine or 10 ml of 0.9% sodium chloride. On the day of colonoscopy randomization will be performed by an independent investigator who is a pharmacist at VA medical center using the website http://www.randomization.com. She will also prepare and dispense medication. Each endoscopy team will consist of an attending gastroenterologist, gastroenterology fellow and two nurses. Medications will be administered by one of the nurses under the direct supervision of the physician. At the start of procedure baseline vitals will be recorded as per our unit's policy. Research medication will be administered 3 minutes prior to administration of other medications. Neither the patient nor the medical staff including the endoscopist will be aware of the contents of the vial. Conscious sedation will be achieved using a combination of intravenous midazolam and fentanyl as standard sedative. Rarely, additional diphenhydramine will be given, on the basis of the judgment of the endoscopist. During the procedure vital signs including oxygen saturation will be monitored at 3-5 minute interval. Procedure related complications, including hypotension, desaturation and cardiac arrhythmia will be managed according to our endoscopy unit policy and protocols. Following the procedure, the nurse and the fellow or the attending will individually rate the quality if sedation on a ten-point Likert scale. Qualitative assessment will also be made (Under-sedated, adequately sedated, or over-sedated). Recovery time will be recorded. Day Following the Colonoscopy Twenty-four hour discharge a follow up call will be made and the patients will be asked to evaluate the level of sedation on a 10-point scale (1, inadequate; 10 completely without discomfort); pain (1, no pain; 10 severe pain), and amnesia (10, no memory of the procedure; 1 complete memory).

Official Title
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Use of Diphenhydramine as an Adjunctive Sedative for Colonoscopy in Patients Chronically on Opioids

Conditions
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Colonoscopy, Adjunct Anesthesia Medication

Intervention / Treatment
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* Drug: Diphenhydramine
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients aged 18-64 years undergoing screening, surveillance, diagnostic and therapeutic colonoscopy Patient on chronic opioids defined as at least 5 mg of morphine or its equivalent at least 3 days per week for more than 3 months Exclusion Criteria: Inability to execute informed consent Allergy to Diphenhydramine, fentanyl or midazolam Known or suspected pregnancy Endoscopic procedure without sedation Patient scheduled to have other endoscopic procedures on the same day Prior alimentary tract surgery Severe cardiopulmonary disease (ASA IV) Monoamine Oxidase Inhibitors (MOI) use within 2 weeks of procedure

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 64 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Diphenhydramine<br>Diphenhydramine 50 mg IV 3 minutes prior to administration of other sedatives | Drug: Diphenhydramine<br> <br> * Other names: Benadryl;|
| Placebo Comparator: Placebo<br>0.9% sodium chloride 10 ml IV 3 minuted prior to administration of other sedatives | Drug: Placebo<br> <br> * Other names: 0.9% sodium chloride;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Dosage of Fentanyl | Moderate sedation (using the American Society of Anesthesiologists definition of maintaining purposeful response to verbal or tactile stimulation, adequate ventilation requiring no airway protection, and maintenance of cardiovascular function) was then achieved using incremental doses of the combination of intravenous midazolam (1 mg) and fentanyl (25 μg) given every 2 to 3 minutes. To minimize any crossover, additional diphenhydramine was not permitted. | From induction (first dose of sedative) to end of procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Quality of Sedation | Quality of sedation will be accessed by the nurse and the physician at the end of procedure. Name: 10 point visual analogue scale Minimum score: 1 (worse) Maximum score: 10 (better) | During the colonoscopy and 24 hours after discharge | 
| Duration of Procedure | Induction period (time from first dose of fentanyl to scope insertion), procedural time (time from scope insertion to scope out), and recovery time (time from scope out to discharge) were recorded by the nursing staff in their standard documentation. | Time from induction (first dose of sedative) to discharge | 
| Number of Participants With Adverse Events | Following adverse events will be recorded: (1)Hypoxia defined as O2 saturation less than 89% lasting for more than 30 seconds, (2)hypotension defined as systolic BP less than 90 mmhg and (3)use of reversal agents i.e Naloxone or Flumazenil | From induction (first dose of sedative) to discharge | 
| 24 Hour Follow up Pain Score | At 24 hr follow up patients were asked to rate the level of pain during the procedure using 10 point scale. 10 point visual analogue scale minimum= 0 (better) maximum =10 (worse) | About 24 hours after the procedure | 
| Dosage of Midazolam | Moderate sedation (using the American Society of Anesthesiologists definition of maintaining purposeful response to verbal or tactile stimulation, adequate ventilation requiring no airway protection, and maintenance of cardiovascular function) was then achieved using incremental doses of the combination of intravenous midazolam (1 mg) and fentanyl (25 μg) given every 2 to 3 minutes. To minimize any crossover, additional diphenhydramine was not permitted. | From induction (first dose of sedative) to end of procedure | 
| 24 Hour Follow up Amnesia Score | Patient were also asked to rate amnesia on a 10 point scale 24 after discharge. minimum= 0 (worse) maximum =10 (better) | At about 24 after the procedure | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Fentanyl, Midazolam, Sedation, Patient tolerance, Duration of colonoscopy