[Special ginkgo extract in cases of vertigo: a systematic review of randomised, double-blind, placebo controlled clinical examinations]

[Comprehensive approach to vertigo: Diagnostic algorithm, causes, treatments, and referral criteria from the perspective of primary care. SEMERGEN consensus document]

Vertigo is a common symptom that can have various causes and may require a comprehensive approach for its diagnosis and treatment from primary care. A diagnostic algorithm based on the classification proposed by the Otoneurology Commission of the SEORL-PCF is suggested, which facilitates the classification of the different types of vertigo and provides referral criteria for patients from primary care to other specialties. A review of the available treatments based on the underlying cause is conducted for appropriate therapeutic management. This document is expected to become a valuable tool for professionals treating patients with vertigo. The document is based on scientific evidence and on the experience of experts in the field from various medical specialties; and seeks to improve the understanding and clinical approach to acute vertigo from primary care.

Pharmacologic treatments in preclinical tinnitus models with special focus on Ginkgo biloba leaf extract EGb 761®

Tinnitus is defined as the perception of sound in the absence of external acoustic stimuli. Frequent comorbidities or associated factors are depression, anxiety, concentration problems, insomnia, resignation, helplessness, headache, bruxism, or social isolation, just to name a few. Although many therapeutic approaches have already been tested with varying success, there still is no cure available for tinnitus. The search for an effective treatment has been hampered by the fact that the mechanisms of tinnitus development are still not fully understood, although several models are available and discussed in this review. Our review will give a brief overview about preclinical models, presenting the heterogeneity of tinnitus sub-types depending on the different inner ear and brain structures involved in tinnitus etiology and pathogenesis. Based on these models we introduce the different target structures and transmitter systems implicated in tinnitus development and provide an extensive overview on preclinical drug-based therapeutic approaches that have been explored in various animal models. As the special extract from Ginkgo biloba leaves EGb 761® has been the most widely tested drug in both non-clinical tinnitus models as well as in clinical trials, a special focus will be given to EGb 761®. The efficacy of terpene lactones, flavone glycosides and proanthocyanidines with their distinct contribution to the overall efficacy profile of the multi-constituent drug EGb 761® will be discussed.

Current and Emerging Medical Therapies for Dizziness

Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.

[Update on diagnosis and therapy in frequent vestibular and balance disorders]

The 8 most frequent vestibular disorders account for more than 70% of all presentations of vertigo, dizziness, and imbalance. In acute (and mostly non-repetitive) vestibular disorders acute unilateral vestibulopathy and vestibular stroke are most important, in episodic vestibulopathies benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, and in chronic vestibular disorders bilateral vestibulopathy/presbyvestibulopathy, functional dizziness and cerebellar dizziness. In the last decade, internationally consented diagnostic criteria and nomenclature were established for the most frequent vestibular disorders, which can be easily applied in clinical practice. The diagnostic guidelines are based on history taking (including onset, duration, course, triggers, accomanying symptoms), clinical examination, and only a few apparative tests (by videooculography and audiometry) for securing the diagnosis. Treatment of vestibular disorders includes physical training (repositioning maneuvers, multimodal balance training) and pharmacological approaches (e.g., corticosteroids, antiepileptics, antidepressants, potassium-canal-blockers, drugs enhancing neuroplasticity). For most drugs, high-level evidence from prospective controlled trials is lacking. In clinical practice, the most frequent vestibular disorders can be treated effectively, thus avoiding chronicity and secondary comorbidity (by immobility, falls or psychiatric disorders such as anxiety or depression).

Advances in pharmacotherapy of vestibular and ocular motor disorders

INTRODUCTION

Vertigo and dizziness are common chief complaints of vestibular and ocular motor disorders (lifetime prevalence 30%). Treatment relies on physical, pharmacological, psychological and rarely surgical approaches. Eight groups of drugs are currently used in vestibular and ocular motor disorders, namely anti-vertiginous, anti-inflammatory, anti-menière's, anti-migrainous medications, anti-depressants, anti-convulsants, aminopyridines and agents that enhance vestibular plasticity.

AREAS COVERED

The purpose of this review is to summarize the pharmacological characteristics and clinical applications of medications that are used for peripheral, central and functional vestibular and ocular motor disorders. The level of evidence for the respective drugs is described alongside the pathophysiological premises supporting their use. The authors place particular focus on translation and back-translation in vestibular pharmacological research and the repurposing of known drugs for new indications and rare disorders.

EXPERT OPINION

The use of drugs in vestibular and ocular motor disorders is often based on open-label, non-controlled studies and expert opinion. In the future, strong evidence derived from RCTs is needed to support the effectiveness and tolerability of these therapies in well-defined vestibular and ocular motor disorders. Vestibular pharmacological research must be guided by a better understanding of the molecular targets relevant in the pathophysiology of vestibular and ocular motor disorders.

Therapeutic efficacy of the Ginkgo special extract EGb761® within the framework of the mitochondrial cascade hypothesis of Alzheimer's disease

OBJECTIVES

The mitochondrial cascade hypothesis of dementia assumes mitochondrial dysfunction as an important common pathomechanism for the whole spectrum of age-associated memory disorders from cognitive symptoms in the elderly over mild cognitive impairment to Alzheimer's dementia. Thus, a drug such as the Ginkgo special extract EGb 761^® which improves mitochondrial function should be able to ameliorate cognitive deficits over the whole aging spectrum.

METHODS

We review the most relevant publications about effects of EGb 761^® on cognition and synaptic deficits in preclinical studies as well as on cognitive deficits in man from aging to dementia.

RESULTS

EGb 761^® improves mitochondrial dysfunction and cognitive impairment over the whole spectrum of age-associated cognitive disorders in relevant animal models and in vitro experiments, and also shows clinical efficacy in improving cognition over the whole range from aging to Alzheimer's or even vascular dementia.

CONCLUSIONS

EGb 761^® shows clinical efficacy in the treatment of cognitive deficits over the whole spectrum of age-associated memory disorders. Thus, EGb 761^® can serve as an important pharmacological argument for the mitochondrial cascade hypothesis of dementia.

Ginkgo biloba Extract EGb 761 Improves Vestibular Compensation and Modulates Cerebral Vestibular Networks in the Rat

Unilateral inner ear damage is followed by behavioral recovery due to central vestibular compensation. The dose-dependent therapeutic effect of Ginkgo biloba extract EGb 761 on vestibular compensation was investigated by behavioral testing and serial cerebral [¹⁸F]-Fluoro-desoxyglucose ([¹⁸F]-FDG)-μPET in a rat model of unilateral labyrinthectomy (UL). Five groups of 8 animals each were treated with EGb 761-supplemented food at doses of 75, 37.5 or 18.75 mg/kg body weight 6 weeks prior and 15 days post UL (groups A,B,C), control food prior and EGb 761-supplemented food (75 mg/kg) for 15 days post UL (group D), or control food throughout (group E). Plasma levels of EGb 761 components bilobalide, ginkgolide A and B were analyzed prior and 15 days post UL. Behavioral testing included clinical scoring of nystagmus, postural asymmetry, head roll tilt, body rotation during sensory perturbation and instrumental registration of mobility in an open field before and 1, 2, 3, 5, 7, 15 days after UL. Whole-brain [¹⁸F]-FDG-μPET was recorded before and 1, 3, 7, 15 days after UL. The EGb 761 group A (75 mg/kg prior/post UL) showed a significant reduction of nystagmus scores (day 3 post UL), of postural asymmetry (1, 3, 7 days post UL), and an increased mobility in the open field (day 7 post UL) as compared to controls (group E). Application of EGb 761 at doses of 37.5 and 18.75 mg/kg prior/post UL (groups B,C) resulted in faster recovery of postural asymmetry, but did not influence mobility relative to controls. Locomotor velocity increased with higher plasma levels of ginkgolide A and B. [¹⁸F]-FDG-μPET revealed a significant decrease of the regional cerebral glucose metabolism (rCGM) in the vestibular nuclei and cerebellum and an increase in the hippocampal formation with higher plasma levels of ginkgolides and bilobalide 1 and 3 days post UL. Decrease of rCGM in the vestibular nucleus area and increase in the hippocampal formation with higher plasma levels persisted until day 15 post UL. In conclusion, Ginkgo biloba extract EGb 761 improves vestibulo-ocular motor, vestibulo-spinal compensation, and mobility after UL. This rat study supports the translational approach to investigate EGb 761 at higher dosages for acceleration of vestibular compensation in acute vestibular loss.

[The diagnostics and treatment of tympanophonia]

Tympanophonia can be a consequence of a variety of diseases and pathological conditions diagnostics of which encounters difficulties. The comprehensive clinical examination of the patient is necessary to determine the cause of tympanophonia including elucidation of the following characteristics: initial (acute or gradual) sensation of sound in the ear(s), duration of persisting clinical manifestations, the presence of an acoustic or craniocerebral injury, characteristics of the noise, viz. continuous or intermittent, clicking sounds, paroxysmal or pulsed noise (synchronous with the heart beating), fluctuating, audible to the patient alone or to the surrounding people as well, unilateral and bilateral noises (either symmetric or asymmetric), perception of noise in the head rather than ears., high- and low-pitched noise together with the accompanying neurological symptoms. The analysis of these characteristics makes it possible to differentiate between objective and subjective sensation of noise in the ear(s), determine the amount of additional studies needed for the evaluatio of the conditions of a given patient, identify the possible cause of tympanophonia, establish the nosological diagnosis, and distinguish a group of the patients in need of emergency otological management.

Ginkgo biloba extract EGb 761® alleviates neurosensory symptoms in patients with dementia: a meta-analysis of treatment effects on tinnitus and dizziness in randomized, placebo-controlled trials

Background

Tinnitus and dizziness are frequent in old age and often seen as concomitant symptoms in patients with dementia. In earlier clinical trials, Ginkgo biloba extract EGb 761^® was found to alleviate tinnitus and dizziness in elderly patients. Consequently, a meta-analysis was conducted to evaluate the effects of EGb 761^® at a daily dose of 240 mg on tinnitus and dizziness associated with dementia.

Methods

Randomized, placebo-controlled clinical trials of G. biloba extract EGb 761^® identified by a systematic database search were included in a meta-analysis if they met all of the following selection criteria: 1) diagnosis of dementia according to generally accepted criteria, 2) treatment period of at least 20 weeks, 3) outcome measures covering at least two of the three conventional domains of assessment, 4) presence and severity of dizziness and tinnitus were assessed, and 5) assessment was done before and after randomized treatment.

Results

Five trials that met the inclusion criteria were included in the meta-analysis. The risk of bias was judged as low, with Jadad scores of 3 and 5. In all trials, 11-point box scales were used to assess the severity of tinnitus and dizziness. Overall, EGb 761^® was superior to placebo, with weighted mean differences for change from baseline, calculated in meta-analyses using random effects models, of -1.06 (95% CI: -1.77, -0.36) for tinnitus (p = 0.003) and -0.77 (95% CI: -1.44, -0.09) for dizziness (p = 0.03).

Conclusion

Our findings support the notion that EGb 761^® is also effective in alleviating concomitant neurosensory symptoms in patients with dementia.

Efficacy of steroid therapy based on symptomatic and functional improvement in patients with vestibular neuritis: a prospective randomized controlled trial

The aim of this study was to examine the efficacy of methylprednisolone in vestibular neuritis (VN) by objective and subjective measures. This prospective controlled randomized study was conducted at one tertiary hospital. Twenty-nine VN patients were randomized to either the steroid (n = 15) or the control (n = 14) group. The steroid group received methylprednisolone for 2 weeks, whereas control patients did not; both groups underwent regular vestibular exercises and were prescribed a Ginkgo biloba. Vestibular function tests including caloric test, video head impulse test (vHIT), and sensory organization test (SOT) were performed, and dizziness handicap index (DHI) was determined at enrollment; all tests were repeated at 1 and 6 months after enrollment. Both groups showed statistically significant improvements in caloric weakness and vHIT gain at 1- and 6-month follow-up evaluations compared to the initial examination; however, differences were not significant. The rates of normalization of canal paresis at 1 and 6 months were 50 and 64% in the control group and 33 and 60% in the steroid group, respectively, with no differences between the two groups. The rates of vHIT normalization at 1 and 6 months after treatment were 57 and 78% in the control group and 53 and 87% in the steroid group, respectively, with no differences between the two groups. Finally, there were no significant differences in the improvement of composite scores of SOT and the DHI scores between the two groups. In this prospective RCT, methylprednisolone had no additional benefit in patients with VN who underwent vestibular exercises and received a Ginkgo biloba.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier, NCT02098330; Trial title, The Efficacy of Steroid Therapy in Vestibular Neuritis.

[The influence of Memoplant monotherapy on the dizziness]

The objective of the present work was to study the influence of the dry extract from the leaves of Ginkgo biloba EGb 761 (used as monotherapy at a dose of 120 mg twice daily during 4 months) on the vestibular function of the patients presenting with cochleovestibular pathology of peripheral and mixed genesis. We present the results obtained by the objective and subjective methods for the evaluation of the vestibular function as well as the neurological and psychoemotional state of the 40 patients that was carried out during the four months of memoplant monotherapy. It is concluded that monotherapy with the use of the dry extract from Ginkgo biloba leaves can be applied for the purpose of improvement of static and dynamic balancing state. Moreover, this memoplant preparation can be used as a means of prophylaxis of recurrent dizziness that in addition reduces the severity of anxiety and depression without producing adverse side effects.

Meta-analysis of the efficacy and safety of Ginkgo biloba extract for the treatment of dementia

BACKGROUND

The benefit of Ginkgo biloba for the treatment of dementia remains controversial. The aim of this study was to evaluate the efficacy and safety of Ginkgo biloba in patients with dementia in whom administration effects were reported using meta-analysis.

METHODS

We searched MEDLINE, Embase, the Cochrane databases, and Ichushi for controlled trials of Ginkgo biloba for the treatment dementia. Clinical characteristics and outcomes were extracted. Meta-analysis results were expressed as standard mean differences (SMDs) in scores of the Syndrome Kurztest (SKT), Alzheimer's Disease Assessment Scale Cognitive Subscale (ADAS-Cog) for cognition efficacy, or odds ratios (ORs) for dropouts and adverse drug reactions.

RESULTS

Thirteen studies using the extract EGb761 met our inclusion criteria, which were duration of 12 to 52 weeks and daily dose of more than 120 mg, and included a total of 2381 patients. Meta-analysis was performed by using 9 of 13 studies, 7 of which used the SKT and 2 ADAS-Cog (dose 120 mg, 26 weeks) scores as efficacy parameters. In meta-analysis of all patients, SMDs (95% confidence interval [CI]) in the change in SKT scores (7 studies) were in favor of Ginkgo biloba over placebo (SMD = -0.90 [-1.46, -0.34]), but 2 studies that used ADAS-Cog did not show a statistically significant difference from placebo for ADAS-Cog (-0.06 [-0.41, 0.30]). For Alzheimer's disease (AD) and vascular dementia (VaD) subgroups, SMDs [95% CI] in SKT in the combined AD and VaD subgroup (-1.07 [-1.66, -0.47]) and AD subgroup (-1.36 [-2.27, -0.46]) were in favor of Ginkgo biloba over placebo. In terms of daily dose of Ginkgo biloba in the combined AD and VaD subgroup, SMD in SKT score in 240-mg daily dose groups was significantly greater than with placebo (-0.71 [-1.28, -0.14]). Dropout rates for any reason did not differ between two groups, but dropout rates due to side effects were significantly lower in Ginkgo biloba groups compared with placebo groups (OR = 1.72 [1.06, 2.80]).

CONCLUSIONS

Taking a 240-mg daily dose of Ginkgo biloba extract is effective and safe in the treatment of dementia.

Treatment of Vertigo: A Randomized, Double-Blind Trial Comparing Efficacy and Safety of Ginkgo biloba Extract EGb 761 and Betahistine

A multicenter clinical trial was performed to compare the efficacy and safety of Ginkgo biloba extract EGb 761 and betahistine at recommended doses in patients with vertigo. One hundred and sixty patients (mean age 58 years) were randomly assigned to double-blind treatment with EGb 761 (240 mg per day) or betahistine (32 mg per day) for 12 weeks. An 11-point numeric analogue scale, the Vertigo Symptom Scale—short form, the Clinical Global Impression Scales and the Sheehan Disability Scale were used as outcome measures. Both treatment groups were comparable at baseline and improved in all outcome measures during the course of treatment. There was no significant intergroup difference with regard to changes in any outcome measure. Numerically, improvements of patients receiving EGb 761 were slightly more pronounced on all scales. Clinical global impression was rated “very much improved” or “much improved” in 79% of patients treated with EGb 761 and in 70% receiving betahistine. With 27 adverse events in 19 patients, EGb 761 showed better tolerability than betahistine with 39 adverse events in 31 patients. In conclusion, the two drugs were similarly effective in the treatment of vertigo, but EGb 761 was better tolerated. This trial is registered with controlled-trials.com ISRCTN02262139.

Inner ear symptoms and disease: pathophysiological understanding and therapeutic options

In recent years, huge advances have taken place in understanding of inner ear pathophysiology causing sensorineural hearing loss, tinnitus, and vertigo. Advances in understanding comprise biochemical and physiological research of stimulus perception and conduction, inner ear homeostasis, and hereditary diseases with underlying genetics. This review describes and tabulates the various causes of inner ear disease and defines inner ear and non-inner ear causes of hearing loss, tinnitus, and vertigo. The aim of this review was to comprehensively breakdown this field of otorhinolaryngology for specialists and non-specialists and to discuss current therapeutic options in distinct diseases and promising research for future therapies, especially pharmaceutic, genetic, or stem cell therapy.

Phytotherapeutic and naturopathic adjuvant therapies in otorhinolaryngology

Phytotherapeutic pharmaceuticals and herbal medicinal products with its roots in classical phytotherapeutic medicine have a well-established role in otolaryngological therapy, especially for diseases of the upper airways and acute and chronic infections. A thorough selection and application could mean huge benefit for the patient, in particular in cases with contraindications, chemo- and antibiotic resistance or patient request. Besides, it might spare other medications. Phytotherapeutic pharmaceuticals must fulfil the same criteria of quality, effectiveness and harmlessness of evidence-based medicine like chemical pharmaceuticals, although they are often prescribed due to its well established or traditional based use. This review focuses on phytotherapeutic therapies well established within the European Community for otolaryngologic disease patterns by referring to clinical studies or meta-analysis.