Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomized, Non-inferiority Clinical Trial

Comparison of the Efficacy of Vestibular Rehabilitation and Pharmacological Treatment in Benign Paroxysmal Positional Vertigo

Aim: The aim of the study is to compare the effects of vestibular rehabilitation and pharmacological treatment in benign paroxysmal positional vertigo (BPPV). Materials and methods: Thirty patients (40.93 ± 8.66 years old) diagnosed with BPPV were recruited. Patients were equally divided into pharmacological control group and vestibular rehabilitation group. The pharmacological control group was further divided into Group A (n = 8, 2 doses/day, 24 mg betahistine) and Group B (n = 7, 1 dose/day, 50 mg dimenhydrinate in addition to betahistine). Patients in the rehabilitation group underwent repeated head and eye movements, and Epley or Barbecue Roll Maneuvers were applied for 4 weeks. Subjective assessment of vertigo was measured with the visual analog scale. Static balance parameters were measured with the tandem, one-legged stance, and Romberg tests. Dynamic visual acuity was measured with a Snellen chart, and vestibular dysfunction was measured with the Unterberger (Fukuda stepping) test. All parameters were evaluated before and after treatment. Results: Vestibular rehabilitation resulted in greater improvement in severity of vertigo, balance parameters except Romberg test, and vestibular dysfunction than pharmacological therapy (p < 0,001). There was no significant difference in dynamic visual acuity between groups (p = 0,24). The effects of medication with the active ingredients betahistine and dimenhydrinate were similar (p > 0,05). Conclusion: The vestibular rehabilitation method can positively change the severity of vertigo, balance ability, and vestibular dysfunction compared to pharmacological therapy. Dimenhydrinate administered in combination with betahistine was not superior to betahistine alone but can be recommended for its antiemetic effect.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03598-4.

Efficacy and Safety of a Fixed-Dose Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg in the Treatment of Patients with Vestibular Vertigo: An Individual Patient Data Meta-Analysis of Randomised, Double-Blind, Controlled Clinical Trials

Background and Objective

The source data of four individual randomised, double-blind, reference- and/or placebo-controlled clinical trials with virtually identical study design were pooled for the present meta-analysis. The main objective was to further evaluate the efficacy and safety of the fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg in comparison to various other antivertigo treatments in patients suffering from central and/or peripheral vestibular vertigo.

Methods

Adult male and female outpatients were subjected to a 4-week treatment with the fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg, cinnarizine (20 mg, 50 mg), dimenhydrinate (40 mg, 100 mg), betahistine dimesylate (12 mg), betahistine dihydrochloride (16 mg) and placebo, respectively. The primary efficacy endpoint was the reduction of a validated mean vertigo score (MVS), a composite score of 12 individual vertigo symptoms, the intensities of which were each evaluated by the patients on a 5-point visual analogue scale. For analysis of primary and further secondary efficacy endpoints, baseline-adjusted analysis of covariance (ANCOVA) was used to calculate adjusted least squares means (LSM) with associated two-sided 95% confidence intervals (CIs) for the difference in MVS reductions between treatment groups. Moreover, various sensitivity analyses, responder and subgroup analyses as well as descriptive analyses with respect to safety/tolerability of the treatments were conducted.

Results

Of 795 randomised patients, 779 belonged to the intent-to treat (ITT) and 723 to the per-protocol (PP) population. The main efficacy analysis was based on the ITT population (mean age 52.1 years, 61% female). The mean decrease of the MVS from baseline to Week 4 in the cinnarizine/dimenhydrinate group (−1.10) proved to be significantly larger than in any of the comparator groups. LSM differences for comparators versus the fixed combination ranged between 0.16 (95% confidence interval (CI) 0.03; 0.30, p = 0.017) for cinnarizine 20 mg and 0.60 (95% CI 0.42; 0.78; p < 0.001) for betahistine dimesylate 12 mg in favour of the fixed combination. Furthermore, after 4 weeks of treatment, 74 patients (24.7%) in the cinnarizine/dimenhydrinate group were completely symptom free (MVS = 0), a significantly greater proportion than in any of the comparator groups. Sensitivity analyses showed that baseline characteristics such as age, sex, duration of vertigo and antivertigo pretreatment had only a very minor and clinically non-relevant impact on the efficacy results regarding the primary efficacy outcome. Subgroup analyses with respect to age groups (< 65 years/≥ 65 years) and sex showed no significant differences in efficacy within any of the treatment groups. All treatments were well tolerated. A total of 55 patients (6.9%) reported 75 non-serious adverse events (AEs), and 19 patients (2.4%) discontinued the study prematurely because of AEs. Nearly 95% of the patients (cinnarizine/dimenhydrinate group: 97.9%) rated the tolerability of the study medications as either “good” or “very good”.

Conclusion

The findings of the present meta-analysis indicate that the fixed combination of cinnarizine and dimenhydrinate is a safe and potentially superior treatment option for patients suffering from central and/or peripheral vestibular vertigo, as compared to current standard treatments such as cinnarizine, dimenhydrinate or betahistine given alone in monotherapy.

Structure-Based Virtual Screening Identifies Novobiocin, Montelukast, and Cinnarizine as TRPV1 Modulators with Anticonvulsant Activity In Vivo

The transient receptor potential vanilloid 1 (TRPV1) receptor is a nonselective cation channel, known to be involved in the regulation of many important physiological and pathological processes. In the last few years, it has been proposed as a promising target to develop novel anticonvulsant compounds. However, thermoregulatory effects associated with the channel inhibition have hampered the path for TRPV1 antagonists to become marketed drugs. In this regard, we conducted a structure-based virtual screening campaign to find potential TRPV1 modulators among approved drugs, which are known to be safe and thermally neutral. To this end, different docking models were developed and validated by assessing their pose and score prediction powers. Novobiocin, montelukast, and cinnarizine were selected from the screening as promising candidates for experimental testing and all of them exhibited nanomolar inhibitory activity. Moreover, the in vivo profiles showed promising results in at least one of the three models of seizures tested.

Drug-Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications

Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug-drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug-drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.

Clinical effects of insulin glargine combined with repaglinide in the treatment of type 2 diabetes

OBJECTIVE

To analyze the clinical effects of insulin glargine combined with repaglinide on the treatment of type 2 diabetes (T2D).

METHODS

One hundred and twelve T2D patients were divided into two groups based on the treatment strategy, the control group (N=56) receiving insulin glargine and the experimental group (N=56) receiving insulin glargine combined with repaglinide. Clinical effects were analyzed and compared between the two groups.

RESULTS

After treatment, the levels of fasting blood glucose (FBG), 2h-postprandial blood glucose (2h-PBG), and glycosylated hemoglobin of the experimental group were significantly lower than those of the control group (P<0.05). The levels of fasting C-peptide (FCP) and 2h-postprandial C-peptide (2h-PCP) of the experimental group were significantly higher than those of the control group (P<0.05) after treatment. Compared with the control group, the therapeutic efficacy was significantly higher (P<0.05), the time to normal blood glucose was notably shorter (P<0.05), and the insulin dosage was considerably lower in the experimental group (P<0.05). The incidence of adverse effects of the experimental group was significantly lower than that of the control group (P<0.05), and the treatment satisfaction of the experimental group was significantly higher than that of the control group (P<0.05).

CONCLUSION

Insulin glargine combined with repaglinide is an effective and safe regimen in clinical practice, which can effectively control the blood glucose level, lower insulin dosage, and reduce adverse effects of T2D.

An effect analysis of vestibular rehabilitation training in vertigo treatment

OBJECTIVE

This study aimed to explore the clinical safety and effectiveness of vestibular rehabilitation training in the treatment of vertigo.

METHODS

Patients with vertigo were randomly divided into an experimental group (51 cases) or a control group (51 cases) and were treated for 4 weeks. The Berg balance scale scores (BBS), the vestibular symptom index (VSI) scores, the balance experiment scores, the UCIA vertigo scores, and the vertigo symptom changes before and after the treatment were recorded, and the treatment success was investigated. At the same time, the patient satisfaction scores and the dizziness handicap inventory (DHI) scores were recorded, and the quality of life after the treatment was evaluated.

RESULTS

After four weeks of treatment, the BBS, VSI, balance test, and UCIA vertigo scores in the experimental group were higher than the corresponding scores in the control group (P<0.05). Meanwhile, the total effective rate and the patient satisfaction in the experimental group were higher than they were in the control group (P<0.05). Compared with the control group, the total index and sub-indexes of the DHI (DHI-P (physical), DHI-F (function), and DHI-E (emotion)) in the experimental group were significantly improved, and the differences were statistically significant (P<0.05). The BBS, VSI, balance test, and UCIA vertigo scores in the two groups after the treatment were better than they were before the treatment (P<0.05).

CONCLUSION

Compared with drug therapy alone, vestibular rehabilitation training combined with common drug therapy can significantly improve the patients' quality of life, better eliminate their vertigo symptoms, and improve their satisfaction.

Novel mTORC1 Inhibitors Kill Glioblastoma Stem Cells

Glioblastoma (GBM) is an aggressive tumor of the brain, with an average post-diagnosis survival of 15 months. GBM stem cells (GBMSC) resist the standard-of-care therapy, temozolomide, and are considered a major contributor to tumor resistance. Mammalian target of rapamycin Complex 1 (mTORC1) regulates cell proliferation and has been shown by others to have reduced activity in GBMSC. We recently identified a novel chemical series of human-safe piperazine-based brain-penetrant mTORC1-specific inhibitors. We assayed the piperazine-mTOR binding strength by two biophysical measurements, biolayer interferometry and field-effect biosensing, and these confirmed each other and demonstrated a structure-activity relationship. As mTORC1 is altered in human GBMSC, and as mTORC1 inhibitors have been tested in previous GBM clinical trials, we tested the killing potency of the tightest-binding piperazines and observed that these were potent GBMSC killers. GBMSCs are resistant to the standard-of-care temozolomide therapy, but temozolomide supplemented with tight-binding piperazine meclizine and flunarizine greatly enhanced GBMSC death over temozolomide alone. Lastly, we investigated IDH1-mutated GBMSC mutations that are known to affect mitochondrial and mTORC1 metabolism, and the tight-binding meclizine provoked 'synthetic lethality' in IDH1-mutant GBMSCs. In other words, IDH1-mutated GBMSC showed greater sensitivity to the coadministration of temozolomide and meclizine. These data tend to support a novel clinical strategy for GBM, i.e., the co-administration of meclizine or flunarizine as adjuvant therapy in the treatment of GBM and IDH1-mutant GBM.

Simultaneous estimation of dimenhydrinate, cinnarizine and their toxic impurities benzophenone and diphenylmethylpiperazine; in silico toxicity profiling of impurities

The British Pharmacopeia (BP) reported that the carcinogenic and hepatotoxic, benzophenone (BZP) is a dimenhydrinate (DMH) impurity. On the other hand, cinnarizine (CIN) is reported to have five impurities (A–E). The toxicity profile of CIN impurities was studied and the in silico data revealed that impurity A [1-(diphenylmethyl)piperazine] (DPP) was the most toxic CIN impurity, and hence it was selected during this work. TLC-densitometric method was developed for separation and simultaneous quantitation of DMH, CIN and their toxic impurities. In the proposed method hexane : ethanol : acetone : glacial acetic acid (7 : 3 : 0.7 : 0.5, by volume) with UV scanning at 225 nm were used. Method validation was carried out according to ICH guidelines and linearity was achieved in the range 0.2–4, 0.5–5, 0.1–2.0, and 0.05–2.2 μg per band for DMH, CIN, BZP and DPP, respectively. On the application of the method to pharmaceutical formulation, no interference from additives was observed. The greenness of the method was evaluated using the analytical eco-scale and the results revealed the low negative environmental impact of the developed method.

TLC-densitometric analysis of dimenhydrinate, cinnarizine and their highly toxic impurities.