Double-blind, randomized, multicenter study comparing the effect of betahistine and flunarizine on the dizziness handicap in patients with recurrent vestibular vertigo

[Betahistine in vestibular disorders: current concepts and perspectives]

The goal of this paper is to review the pharmacological profile of betahistine and evidence for using it in the treatment of common vestibular disorders. Betahistine is a weak agonist for histamine H1 receptors and strong antagonist for histamine H3 receptors. It demonstrates the maximum benefit in different types of peripheral vertigo, especially in Meniere's disease. The best results in decreasing intensity of vertigo, frequency of attacks and stimulation of vestibular compensation were obtained in daily dose 48 mg during 3 months. In benign paroxysmal positional vertigo betahistine is used to treat residual dizziness after successful treatment of otolithiasis and to reduce the severity of vertigo during repositioning maneuvers. In vestibular neuritis betahistine stimulates central compensation during vestibular rehabilitation. A new once-daily drug formulation of modified-release betahistine is non-inferior to traditional and has a comparable safety profile, and could improve patient adherence. The implication of betahistine in the treatment of central vestibular disorders is under-researched. The efficacy of betahistine in increasing of vestibular compensation in post-stroke central vestibular disorders, persistent postural-perceptual dizziness and its role in vestibular migraine need further investigation.

Diagnostic and therapeutic strategies for Meniere's disease of the Japan Society for Equilibrium Research

OBJECTIVE

We provided diagnostic and therapeutic strategies for Meniere's disease in accordance with Japanese Clinical Practice Guideline of Meniere's disease and delayed endolymphatic hydrops 2nd ed. Tokyo: Kanehara Shuppan; 2020 edited by the Japan Society for Equilibrium Research.

METHODS

The Committee for Clinical Practice Guidelines was entrusted with a review of the scientific literature on the above topic. Clinical Questions (CQs) concerning the treatment for Meniere's disease were produced, and the literature according to each of them including CQ was searched. The recommendations are based on the literature review and the expert opinion of a subcommittee.

RESULTS

Diagnosis criteria of Meniere's disease are classified into Meniere's disease with typical cochlear and vestibular symptoms, and atypical Meniere's disease with either cochlear symptoms or vestibular symptoms. Treatment of Meniere's disease was composed of lifestyle changes, medications such as anti-vertigo drugs and diuretics, middle ear positive pressure treatment, and selective destruction of the vestibule.

CONCLUSION

Meniere's disease is diagnosed based on clinical histories and examination findings after processes of differential diagnosis. Treatment option of the disease should be selected in order of invasiveness, according to the severity of the disease and the response to each treatment.

Therapeutic strategies in the treatment of Menière's disease: the Italian experience

PURPOSE

Ménière's disease (MD) is an inner ear disorder of unknown etiology, whose pathological substrate is the endolymphatic hydrops. Different treatments have been proposed; however, evidence of their effectiveness is lacking. The aim of this study was to evaluate by a questionnaire which medical and surgical treatments are used in Italy for the treatment of MD and to compare them with those proposed in other countries.

METHODS

An electronic questionnaire of 40 questions was formulated and sent to Italian otolaryngologist (ENT) divided into two groups: Group 1 ("generalists" 60.8%) and Group 2 ("neurotologist- NO" 39.2%).

RESULTS

One hundred and twenty five ENT replied. Treatment of the acute phase, apart from symptomatics, was based on diuretics that are prescribed by 83.5% of respondents, steroids, prescribed by 66.7%, and vasodilators, prescribed by 22%. In the intercritical phase, 87.2% of respondents recommended low-salt diet, 78.4% of respondents prescribed betahistine, and 52.8% diuretics. Statistical analysis did not show correlation neither with the declared specialization nor with the number of patients treated. In case of failure of medical treatment, IT gentamicin was suggested by 48.8% of the respondents and IT steroids by 40.8%. Statistical analysis showed that generalists prefer IT steroids and NO IT gentamicin (p 0.019). In case of failure of both medical treatment and IT treatment, vestibular neurectomy was indicated by 58.4% of the respondents, 6.4% indicated endolymphatic sac surgery, and 2.4% surgical labyrinthectomy.

CONCLUSION

In Italy, the treatment of MD stand on a gradual approach that starts from the dietary-behavioral changes and a pharmacological therapy based on betahistine. In refractory cases, IT treatment initially with steroids and, therefore, with gentamicin allows the control in vertigo in the majority of cases. In case of failure of IT treatment, VNS is the surgery of choice.

Flunarizine and the risk of parkinsonism in a newly diagnosed type 2 diabetic population in Taiwan: A nested case-control study

Previous studies demonstrated that both diabetes and flunarizine use can increase the risk of parkinsonism. The aim of the current study was to investigate the risk of developing parkinsonism after flunarizine treatment, in a cohort of patients newly diagnosed with type 2 diabetes. We conducted a nested case-control study of a type 2 diabetic cohort from the Taiwan Longitudinal Health Insurance Database 2005 (LHID 2005). Each incident case of parkinsonism, during the period from 2001 to 2013, was randomly matched with 3-10 controls, according to age, sex, calendar year of cohort entry, and the duration of follow-up. Conditional logistic regression was used to estimate the odds ratio (OR) of parkinsonism associated with flunarizine use. The cohort consisted of 44,644 patients with newly diagnosed type 2 diabetes from 2001 to 2013, of whom 464 patients had a parkinsonism event during the follow-up period. The adjusted OR of parkinsonism with relation to flunarizine use was 2.75 (95% confidence interval: 2.26-3.36). There were also duration- and dose-response effects. Compared to those who had not used it, the OR for developing parkinsonism was 1.77 for patients who used flunarizine for less than 1 month. When the exposure period expanded over 3 months, the OR increased to 7.03. Our findings suggested that flunarizine use is a potential risk factor for parkinsonism in patients with newly diagnosed type 2 diabetes, especially when the drug is persistently used for over 3 months.

A Comparison of the Effects and Side Effects of Oral Betahistine with Injectable Promethazine in the Treatment of Acute Peripheral Vertigo in Emergency

Background

Vertigo is an illusion of rotation that is caused by the asymmetry of neurological function of the right and left vestibular nuclei. The aim of this study was to compare the efficacy and side effects of oral betahistine with injectable promethazine in treatment of acute peripheral vertigo.

Methods

In this double-blind clinical trial study, the patients with acute peripheral vertigo were assigned in the two groups: receiving promethazine intramuscularly at a dose of 25 mg (group A) and receiving 8 mg betahistine tablets (group B) and the severity of their vertigo was evaluated on the visual analog scale (VAS) scoring system. In addition, adverse events in both groups of patients were compared and evaluated.

Results

A total of 162 patients (82 subjects in group A) participated in this study. The mean age, gender distribution, intensity and symptoms of vertigo were similar in both groups before the intervention. At 2 and 3 h after the intervention, the score of VAS in patients taking betahistine was significantly higher than promethazine. In addition, the clinical symptoms after taking betahistine were significantly less. Side effects seen in patients taking the promethazine include mainly drowsiness. After taking betahistine, the most common complication was abdominal problems (nausea and vomiting).

Conclusion

The results of this study show that betahistine is a safe and effective drug in controlling patients with acute vertigo and its impact is more than promethazine.

Betahistine plus piracetam dual therapy versus betahistine monotherapy for peripheral vestibular vertigo: a confounder-corrected subanalysis of the OSVaLD study

INTRODUCTION

This subanalysis compared the efficacy of betahistine plus piracetam dual therapy versus betahistine monotherapy using data from OSVaLD, a 3 month, open-label, observational study conducted in 2272 patients with peripheral vestibular vertigo. Of the 1898 patients included in the original efficacy population, 1076 were from countries where betahistine plus piracetam dual therapy was prescribed to >1 patient; 114 of these 1076 patients (11%) received the dual therapy and 567 (53%) were treated with betahistine monotherapy; these patients were selected for analysis.

METHODS

Efficacy was assessed using the Dizziness Handicap Inventory (DHI) total and subscale scores. Propensity-score matching was used to correct potential differences in patient baseline characteristics between treatment groups. In addition, a subgroup analysis evaluated 103 patients treated with betahistine because of insufficient efficacy with their existing treatment.

RESULTS

In the propensity-score matched, total-population evaluation, improvements in the DHI total and subscale scores were numerically greater in the betahistine plus piracetam group (n = 88) versus the betahistine group (n = 89) (DHI total, -42.9 vs. -37.6, respectively; DHI physical, -12.1 vs. -10.4; DHI emotional, -13.5 vs. -13.2) and statistically significant for the DHI functional score (-17.3 vs. -14.0, respectively, p = 0.01). The percentage of patients with no impairment at final visit was 27% with betahistine and 47% with betahistine plus piracetam; odds ratio: 2.3, 95% confidence interval: 1.3-2.4 (p = 0.007). Similar results were obtained in the subgroup analyses for patients whose current vertigo treatment was insufficient. The overall incidence of adverse events was low and similar in both groups, and there were no discontinuations due to drug-related adverse events.

CONCLUSIONS

By using propensity-score matching, which controls for potential heterogeneity in patient baseline characteristics and small patient numbers, the results of this analysis suggest that combined betahistine and piracetam may be more effective than betahistine alone in patients with peripheral vestibular vertigo.

Influência do tratamento com fármacos antivertiginosos sobre o equilíbrio postural e qualidade de vida de indivíduos com queixas de tontura

Resumo: OBJETIVO: avaliar a influência do tratamento com fármacos antivertiginosos sobre a qualidade de vida e o equilíbrio postural de adultos e idosos com queixas de tontura. MÉTODOS: estudo transversal, com amostra de 51 indivíduos portadores de queixas de tontura, divididos em dois grupos, de acordo com o uso (grupo medicado, n=25) ou não (grupo não medicado, n=26) de fármacos antivertiginosos. Foram coletadas informações sobre: caracterização dos sintomas (ficha elaborada pelos pesquisadores), autopercepção de qualidade de vida (Dizziness Handicap Inventory),intensidade de tontura (escala visual analógica de tontura) e equilíbrio postural (plataforma de força). RESULTADOS: verificou-se intensidade moderada de tontura (Média: 4,6 ± 2,8) e impacto negativo das vestibulopatias sobre a qualidade de vida (Média: 47,3 ± 22,4) na amostra total. Quando comparados os dois grupos, não houve diferença estatisticamente significante na intensidade da tontura (p=0,74) ou qualidade de vida (p=0,79), e também, nos parâmetros da estabilometria, em quatro tarefas (teste t independente, p>0,05). Contudo, após a inclusão do tempo de utilização de fármacos antivertiginosos como uma covariável do estudo, foi verificado pior desempenho nas diferentes tarefas da estabilometria no grupo medicado (ANCOVA, p<0,05). CONCLUSÃO: o uso de fármacos antivertiginosos não melhora a qualidade de vida de indivíduos com queixas de tontura e o equilíbrio postural esteve alterado no grupo medicado.

Intratympanic gentamicin treatment for Ménière's disease: a randomized, double-blind, placebo-controlled trial on dose efficacy - results of a prematurely ended study

BACKGROUND

Gentamicin is used as a therapeutic agent for Ménière's disease because of its vestibulotoxicity causing chemo-ablation of the vestibular sensory epithelia. Its use has increased in recent years. However, there is still no consensus about the dose regimen of gentamicin in the treatment of Ménière's disease. In this study two different dose regimen treatment protocols are compared in a placebo controlled study design. The primary objective is to quantify the treatment effect on dizziness, the secondary objective is hearing evaluation.

METHODS

We performed a randomized, double-blind, placebo-controlled study in adults with unilateral Ménière's disease according to the AAO-HNS guidelines resistant to conservative medication. Three groups received four injections, administered weekly (four intratympanic injections with 40 mg/mL gentamicin solution, two injections gentamicin solution and two injections of placebo in random order, or four injections with placebo). Outcome measures were the score on the Dizziness Handicap Inventory and pure tone audiometry (PTA). Intended follow-up was 2 years.

RESULTS

During follow-up one patient exceeded the accepted amount of hearing loss. Further, enrollment was very slow (until 12 months between two patients) and new insights showed an apparent benefit of intratympanic gentamicin treatment (ITG). Therefore we performed an unscheduled interim analysis which showed that PTA threshold shifts reached the stopping criteria in two more patients. Because of this, this study was ended. Of the three patients with the significant PTA threshold shift two were enrolled in the gentamicin group.

CONCLUSION

No conclusions can be drawn concerning doses regimens. Now that new publications have shown that ITG treatment can be an effective and safe treatment, a placebo-controlled randomized controlled trial may not pass the ethical committee because of these recent reports in literature. Still, a dose regimen study (without placebo) on ITG treatment needs to be performed.

TRIAL REGISTRATION

This trial was registered in The University Medical Center Utrecht/ Gelre hospital Apeldoorn. Protocol ID: 07/343, EudraCT number 2006-005913-37.

Comparison of the therapeutic efficacy of intravenous dimenhydrinate and intravenous piracetam in patients with vertigo: a randomised clinical trial

BACKGROUND

The present study aimed to compare the therapeutic efficacy of dimenhydrinate and piracetam in patients with vertigo.

METHODS

A blinded, parallel group, superiority, randomised clinical trial was carried out on patients who presented to the emergency department (ED) with vertigo. Healthy adult patients presenting to the ED with undifferentiated vertigo were included in the study. The efficacy of intravenous dimenhydrinate (100 mg) and intravenous piracetam (2000 mg) for reducing the intensity of vertigo was compared in two randomised treatment groups using a 10-point numeric rating scale (NRS). The determination of NRS scores was performed at presentation and at the 30th minute of presentation, after the study drug was implemented, both in immobile and ambulatory positions. The primary outcome variable was reduction in vertigo intensity documented on the NRS at the 30th minute after medication administration, analysed by intention to treat.

RESULTS

A total of 94 patients were included in the randomisation (n=47 in both groups). The baseline NRS scores were 7.55±2.00 in the dimenhydrinate group and 8.19±1.79 in the piracetam group. The changes from baseline for dimenhydrinate and piracetam were 2.92±3.11 and 3.75±3.40 (difference -0.83 (95% CI -2.23 to 0.57)) in the immobile position and were 2.04±3.07 and 2.72±2.91 (difference -0.68 (95% CI -2.03 to 0.67)) in the ambulatory position. Rescue medication need was similar in both treatment groups (p=0.330), and only one adverse reaction was reported.

CONCLUSIONS

We found no evidence of a difference between dimenhydrinate and piracetam in relieving the symptoms of vertigo.

TRIAL REGISTRATION NUMBER

Clinical Trials Registration ID: NCT01890538.

The evaluation of ozone and betahistine in the treatment of tinnitus

The aim of the study is to evaluate the effectiveness of ozone and betahistine treatments in the treatment of tinnitus. Sixty-eight patients were enrolled in this randomized, prospective controlled study. The ozone group consisted of 27, betahistine group consisted of 26 and control group consisted of 15 patients. The patients in ozone group received 10 sessions of ozone treatment via major autohemotherapy. Betahistine group received 48 mg/day betahistine tablets per oral for 3 months duration. The control group was followed up without any treatment given. The evaluation of tinnitus was made by tinnitus loudness and tinnitus handicap inventory (THI). The changes in findings from baseline to 3rd and 6th months were assessed, and the group results were compared. Comparison of the initial mean tinnitus loudness and 3 and 6 months after treatment in each of the three groups did not reveal a significant difference. The comparison between the groups in terms of the improvement of tinnitus loudness was not significant (p = 0.821). Comparison of the initial mean THI and 3 and 6 months after treatment revealed a significant difference in ozone and betahistine groups but not in the control group. When the delta (Δ) THI (the change of mean THI between the initial and 6th month) was compared between the groups, there was no significant difference. This randomized controlled study investigating the effects of ozone in tinnitus tries to shed light to a new method of treatment in tinnitus. The findings of the study does not provide enough evidence to support ozone and betahistine as a treatment for tinnitus and further research on the subject is necessary.

Comparison of cinnarizine/dimenhydrinate fixed combination with the respective monotherapies for vertigo of various origins: a randomized, double-blind, active-controlled, multicentre study

BACKGROUND AND OBJECTIVE

Vertigo may arise from dysfunction in the peripheral and/or the central vestibular system. Simultaneous activity of a medication at both sites will serve to improve the efficacy of antivertigo treatment. The aim of this study was to compare the efficacy and tolerability of a fixed combination of the peripherally acting cinnarizine (20 mg) plus the centrally acting dimenhydrinate (40 mg) with those of equally dosed monotherapies in the treatment of vertigo of various origins.

METHODS

This prospective, randomized, double-blind, active-controlled, multicentre study included patients who assessed at least one vertigo symptom as being of at least medium intensity (≥2) on a 5-point visual analogue scale (VAS; ranging from 0 = not present to 4 = very strong) and who had pathological vestibulospinal movement patterns and/or nystagmus reactions. Patients were randomly assigned to receive either cinnarizine 20 mg/dimenhydrinate 40 mg as a fixed combination, cinnarizine 20 mg as monotherapy or dimenhydrinate 40 mg as monotherapy, each three times daily for 4 weeks. Patients were examined at baseline (t(0)), and after 1 week (t(1w)) and 4 weeks (t(4w)) of treatment. The primary efficacy endpoint was the decrease in mean vertigo score (MVS) at t(4w), which was calculated by averaging the total score for 12 individual vertigo symptoms, each assessed using the 5-point VAS.

RESULTS

The study included 182 patients, of whom 177 were evaluable for efficacy. The mean ± SD reduction in MVS after 4 weeks of treatment with the fixed combination (-1.44 ± 0.56) was significantly greater than the reductions with each of the active treatments alone (cinnarizine -1.04 ± 0.53; dimenhydrinate -1.06 ± 0.56; p = 0.0001, both comparisons). Cinnarizine 20 mg/dimenhydrinate 40 mg as a fixed combination was associated with a significantly higher responder rate (78% of patients with MVS ≤0.5 at t(4w)) than the monotherapies. The odds ratios for MVS ≤0.5 at t(4w) in the cinnarizine or dimenhydrinate groups versus the fixed combination group were 0.345 and 0.214, respectively. The fixed combination reduced concomitant vegetative symptoms significantly more effectively than cinnarizine at both t(1w) (p < 0.05) and t(4w) (p < 0.01). Nine patients reported 15 adverse events (AEs) [three AEs for the fixed combination, six AEs each for cinnarizine and dimenhydrinate]. At t(4w) the tolerability of the treatments was rated as very good or good by almost all patients in all groups (fixed combination and dimenhydrinate 96.6% each; cinnarizine 98.3%).

CONCLUSION

The fixed combination of cinnarizine 20 mg/dimenhydrinate 40 mg was an effective and well tolerated treatment for patients with vestibular vertigo of central and/or peripheral origin. The efficacy of the fixed combination exceeded that of each of the equally dosed active substances given as monotherapy, leading to higher responder rates, and showed a very good and comparable tolerability with a similar or even smaller rate of adverse events than the active substances given alone.

Management of vestibular migraine

Vestibular migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo. The duration of attacks varies from seconds to days, usually lasting minutes to hours, and they mostly occur independently of headaches. Long-lasting individual attacks are treated with generic antivertiginous and antiemetic drugs. Specific antimigraine drugs are unlikely to be very effective for rescue. The mainstay of the management of vestibular migraine is prophylactic medication. To date, there are no controlled trials available; the body of knowledge builds on case series and retrospective or observational studies. Most drugs are also used for the prevention of migraine headaches. The choice of medication should be guided by its side effect profile and the comorbidities of patients. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. Calcium antagonists include verapamil and flunarizine. If patients have anxiety, tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam are recommended. Acetazolamide is effective in rare genetic disorders related to migraine-like episodic ataxia; however, its place in vestibular migraine is still to be established. Nonpharmacological measures such as diet, sleep, hygiene and avoidance of triggers are recommended as they are for migraine. Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence.

Efeito da reabilitação vestibular em idosos: quanto ao equilíbrio, qualidade de vida e percepção

As atuais preocupações com qualidade de vida (QV), envelhecimento da população, limitações impostas pelos distúrbios do equilíbrio na população idosa e a alternativa de tratamento por meio da reabilitação vestibular (RV) justificaram este estudo. Nele, objetivou-se analisar, perspectivamente, os resultados da aplicação do protocolo de Cawtome & Cooksey para RV, em idosos institucionalizados, com queixas de alterações de equilíbrio e probabilidade de queda (PQ), visando à melhoria da QV e à percepção desses idosos sobre as limitações impostas pelos distúrbios do equilíbrio. Utilizou-se uma metodologia híbrida, buscando a integração de dados quantitativos e qualitativos, associando-se o estudo experimental ao fenomenológico, em uma população de trinta idosos asilados com queixas de alterações do equilíbrio. Os instrumentos de avaliação foram a Escala de Berg, Dizziness Handicap Inventory (DHI) e análise de conteúdo. Como conclusão do estudo, constatou-se que, na população estudada, a RV foi efetiva quanto à melhora dos sintomas de alteração do equilíbrio em relação à QV, à PQ e aos sentimentos de segurança e independência dos idosos.

Comparable efficacy and tolerability between twice daily and three times daily betahistine for Ménière's disease

CONCLUSION

Betahistine at oral doses of 16 mg tid and 24 mg bid provides similar efficacy and tolerability in the treatment of vertigo in patients with Ménière's disease.

OBJECTIVE

To compare the efficacy and tolerability of betahistine 16 mg tid and 24 mg bid in the treatment of vertigo in patients with Ménière's disease.

PATIENTS AND METHODS

This was a randomized, open-label study of 120 consecutive patients with well-established Ménière's disease treated with betahistine 16 mg tid or 24 mg bid for 24 weeks. Treatment efficacy, assessed by clinical outcome level in terms of severity, frequency and duration of vertigo spells, was evaluated at baseline and at weeks 4, 12 and 24. Between-group comparisons of outcome data (Wilcoxon, Mann-Whitney U test) and adverse events (chi-squared test) were made.

RESULTS

Betahistine 16 mg tid or 24 mg bid showed a significant improvement in clinical outcome level from baseline to week 24 (p < 0.01). There was no significant difference between dosage groups regarding improvement in vertigo at any time point during the study. There was no significant difference between groups in the incidence of adverse events, which was low (maximum: headache, 16 mg tid, 16.7% of patients at week 4; 6.7% at week 24). The number of patients reporting adverse events diminished with time.

Migraine-associated risks and comorbidity

This review reports important co-morbid conditions of migraine and resulting consequences for the choice of acute and preventive treatments of migraine. Comorbidity in this context means the occurrence of two diseases in an individual beyond chance. The basis of comorbidity can be genetic and/or based on common environmental factors. In some cases, the temporal relationship is unclear and one disease can cause another disease. In order to prove a real comorbidity, large-scale and well-performed epidemiological studies are required.

Improving the quality of life in patients with vestibular disorders: the role of medical treatments and physical rehabilitation

Vertigo, dizziness and imbalance are the main symptoms of vestibular disorders. They can lead to physical consequences, such as reduced postural control and falls, to psychologic/psychiatric consequences, such as anxiety-depression symptoms, panic and agoraphobia, and to cognitive defects, especially in the elderly. Consequently, the general health status and the quality of life (QoL) of vestibular patients can be significantly impaired. Several questionnaires have been developed in an attempt to quantify the degree of handicap and disability, the self-perceived health status and the quality of life in vestibular patients with dizziness and imbalance. Additionally, the main goal of the treatments of vestibular disorders should be to control symptoms, reduce functional disability and to improve patients' QoL. This article reviews the physical and psychological consequences of the vestibular disorders, their impact on the patients' QoL, and the treatment options, including drug prescriptions and vestibular rehabilitation protocols. A profile of the compound betahistine and its efficacy on QoL indices in the treatment of Menière's disease and other forms of peripheral vertigo is also presented.

Patient baseline characteristics in an open-label multinational study of betahistine in recurrent peripheral vestibular vertigo: the OSVaLD study

OBJECTIVES AND METHODS

OSVaLD (Observational Study in patients suffering from recurrent peripheral vestibular Vertigo to Assess the effect of betahistine 48 mg/day on quality of Life and Dizziness symptoms) is a 3-month, open-label, multi-national post-marketing surveillance study of betahistine 48 mg/day in the management of patients with vertigo of less than 5 years in duration. The aim of the study is to examine the burden of disease associated with vertigo, as determined by scores on the Dizziness Handicap Inventory (DHI), Short Form-36 (SF-36) questionnaire and the Hospital Anxiety and Depression Scale (HADS). Changes in DHI, SF-36 and HADS scores between baseline and 3 months are used to assess the therapeutic effects of betahistine.

RESULTS

Participants (n = 2037) have been recruited from 13 countries in four continents (North and South America, Asia and Europe), representing a wide range of cultural and linguistic traditions. Approximately two-thirds of the patients are women. Sixty per cent of patients have diagnoses of peripheral vestibular vertigo of unknown pathology or benign paroxysmal positional vertigo; 13% have a diagnosis of Ménière's disease. All three of the instruments used characterize this as a population with extensive vertigo-attributable morbidity at baseline. The mean DHI score of the population is 63.7 +/- 15.7 (DHI scale: 0 = no handicap; 100 = major self-perceived handicap), SF-36 scores in all domains are below the population average for the USA and the HADS indicated that > 50% of patients exhibit symptoms of anxiety or depression or both, including 9% who have severe manifestations of either or both conditions.

CONCLUSIONS

This report describes the design and implementation of OSVaLD and presents baseline demographic and clinical features of the patients. Full results of the study, anticipated in 2007, will provide more details about the manifestations of vertigo in routine practice and the response to betahistine.

Betahistine: a retrospective synopsis of safety data

Betahistine is a structural analogue of histamine that is prescribed for the treatment of vestibular disorders such as Ménière's disease and the symptomatic treatment of vertigo. It is estimated from sales information that >130 million patients have been exposed to the drug since its registration in 1968. In this review we analyse the safety profile of betahistine based on data obtained during >35 years of worldwide postmarketing surveillance. Until 31 December 2005, 554 adverse drug reaction (ADR) reports with 994 individual signs and symptoms were received by the marketing authorisation holder from worldwide sources and were reviewed and evaluated. Signs and symptoms of cutaneous hypersensitivity reactions during betahistine therapy were the most frequently reported complaints. They consisted of usually mild and self-limiting rash, pruritus and urticaria, and all symptoms were reversible after drug discontinuation. Betahistine was reported to be involved in one anaphylactoid reaction and one case of Stevens-Johnson syndrome. Anaphylactic reactions with fatal outcome were not reported. The reports that describe gastrointestinal complaints mostly concern nausea and vomiting or unspecific abdominal pain. These were typically non-serious complaints. Hepatobiliary involvement was reported 25 times, including increases in alkaline phosphatase, gamma-glutamyltransferase, and alanine and aspartate aminotransferase levels. None of the patients concerned developed severe liver failure or died. ADRs related to the nervous system predominantly reveal heterogeneous events that are not suggestive of a specific adverse reaction profile for betahistine. A clinical intolerance to betahistine that gave rise to asthma or bronchospasm was only reported in eight ADRs. A total of three cases of neoplasm have been reported. One case concerned a male patient of unknown age who experienced weight loss, insomnia, impatience and irritability soon after the start of betahistine therapy. An undiagnosed phaeochromocytoma was suspected. The remaining two cases were assessed as being unrelated to betahistine by the reporter. Finally, four deaths have been reported during the course of postmarketing surveillance for betahistine. The reporter assessed the causal relationship to betahistine in two as unrelated, in one as unlikely and the other as unassessable. In summary, clinical and postmarketing studies have revealed a good safety profile of betahistine that was confirmed by the safety surveillance data presented.

Menière's disease: myths and realities

Many of the theories of the aetiology and pathogenesis of Menière's disease are often taught as being fact. This article explores how flimsy the evidence is for these theories along with the evidence of the effectiveness of the many treatments available.