Effects of high-dose betahistine on intractable dizziness in patients with uncompensated unilateral vestibulopathy

OBJECTIVE

In the present study, we examined the effects of high-dose betahistine on dizziness handicap inventory (DHI) scores in patients with unilateral vestibulopathy.

METHODS

An uncontrolled, open-label, multicenter clinical trial was conducted. Fifteen patients with unilateral vestibulopathy, such as vestibular neuritis, who complained of intractable dizziness for more than three months were enrolled. Initially, all patients were orally administered betahistine at a dose of 36 mg/day for four weeks, which is the standard dose and dosing period for the treatment of dizziness in Japan. The patients were then administered betahistine at a double dose of 72 mg/day for four weeks. Six patients who became aware of the benefits of high-dose betahistine were further administered betahistine at 72 mg/day for an additional 12 weeks (a total of 16 weeks). Perceived disability due to dizziness was assessed by DHI scores.

RESULTS

In all 15 patients, short-term administration with high-dose (72 mg/day) betahistine for four weeks, but not low-dose betahistine (36 mg/day) for four weeks significantly decreased DHI scores. In particular, in six responding patients with self-reported benefits after short-term administration with high-dose betahistine, long-term administration with high-dose betahistine for 16 weeks further significantly decreased DHI scores. However, DHI scores of the remaining nine non-responding patients were not changed after short-term administration with high-dose betahistine for four weeks.

CONCLUSION

Short-term administration with the standard dose and dosing period of betahistine did not improve DHI scores in the enrolled patients, indicating that they were not compensated for unilateral vestibulopathy with intractable dizziness. The present findings suggest that long-term administration with high-dose betahistine facilitates vestibular compensation to improve intractable dizziness in some, but not all patients with uncompensated unilateral vestibulopathy.

Historical Therapies for Suspected Autonomic Dysregulation in Meniere's Disease

OBJECTIVE

This narrative review examines how speculative belief that the autonomic nervous system causes Meniere's Disease (MD) led otolaryngologists to adopt invasive surgical procedures and medical treatments still offered today.

DATA SOURCES

Google Scholar, PubMed.

REVIEW METHODS

A comprehensive literature review (1860-2022) was performed using the terms "Meniere AND (sympathetic OR sympathectomy OR vasomotor OR cervical ganglion)," returning 5360 items. All abstracts were briefly reviewed, relevant publications selected for further study, and key articles discussed by all authors. As it became clear that betahistine was related to the historical narrative, an additional search was performed using "Betahistine AND Meniere AND (vasomotor OR sympathetic OR sympathectomy OR cervical ganglion OR autonomic)," which yielded 336 results.

RESULTS

In the 19th and 20th centuries, growing knowledge of human anatomy led the scientific community to speculate that autonomic dysregulation caused many medical conditions. Excessive sympathetic mediated vasomotor changes were thought to cause hypertension, ischemia, and tissue damage. Clinicians applied the hypothesis to MD, assigning the sympathetic nervous system responsible for vertigo secondary to paroxysmal vasospasm and for hearing loss to poor cochlear nutrition. Despite limited animal experiments and isolated clinical observations, otolaryngologists performed sympathectomies, and, in the 1970s, replaced the procedure with betahistine as an alternative medical treatment.

CONCLUSION

Premature excitement about a plausible hypothesis led to unnecessary and unwarranted operations. Despite absent evidence of sympathetic overactivation in MD, surgeons eagerly adopted sympathectomies, and later betahistine. Rigorous evaluation of the validity of these treatment practices is needed.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:535-542, 2024.

Meniere Disease treated with transcutaneous auricular vagus nerve stimulation combined with betahistine Mesylate: A randomized controlled trial

BACKGROUND

Meniere Disease is a clinical condition defined by hearing loss, tinnitus, and aural fullness symptoms, there are currently no any medications approved for its treatment.

OBJECTIVE

To determine whether taVNS as an adjunctive therapy could relieve symptoms and improve the quality of life in patients with Meniere disease.

METHODS

In this Single-center, single blind, randomized trial, participants were assigned to transcutaneous auricular vagus nerve stimulation (taVNS) group and sham taVNS group. The primary outcome measures comprised Tinnitus Handicap Inventory, Dizziness Handicap Inventory, Pure Tone Auditory, Visual analogue scale of aural fullness. Secondary outcome measures comprised the 36-Item Short Form Health Survey, video head impulse test, and the caloric test.

RESULTS

After 12 weeks, the THI (-11.00, 95%CI, -14.87 to -7.13; P < 0.001), DHI (-47.26, 95%CI, -50.23 to -44.29; P < 0.001), VAS of aural fullness (-2.22, 95%CI, -2.95 to -1.49; P<0.01), and Pure Tone Thresholds (-7.07, 95%CI, -9.07 to -5.06; P<0.001) were significantly differed between the two groups. In addition, SF36(14.72, 95%CI, 11.06 to 18.39; P < 0.001), vHIT (RD, 0.26, 95 % CI, -0.44 to -0.08, RR, 0.43, 95 % CI, 0.22 to 0.83, P < 0.01), and the caloric test (RD, -0.24, 95 % CI, -0.43 to -0.04, RR, 0.66, 95 % CI, 0.44 to 0.95, P = 0.02) have significant difference between two group, respectively.

CONCLUSIONS

These findings suggest that taVNS combined with Betahistine Mesylate relieve symptoms and improve the quality of life for patients with Meniere Disease. taVNS can be considered an adjunctive therapy in treatment of Meniere Disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05328895.

Effect of betahistine treatment on dizziness and anxiety symptoms of BPPV patients

Background

Patients with benign paroxysmal positional vertigo (BPPV) may experience significant deterioration in their quality of life due to dizziness and anxiety symptoms.

Aim

To evaluate the effect of betahistine add-on therapy on dizziness and anxiety symptoms of BPPV patients.

Materials and Methods

Eighty-four patients who were diagnosed as having posterior canal BPPV were included in the study. Patients were divided into two groups according to the treatment regimen: Group 1 included 42 subjects who were treated with the Epley maneuver alone and Group 2 included 42 subjects who received betahistine 48 mg/day for ten days with the Epley maneuver. Dizziness handicap inventory (DHI) and Beck anxiety inventory (BAI) were evaluated at the time of diagnosis and at the control examination on the tenth day.

Results

The mean before and after treatment DHI scores were 38.8 ± 14.6 and 5.47 ± 6.4 for Group 1 (P < 0.001), and 45.8 ± 21.1 and 10.3 ± 12.9 for Group 2 (P < 0.001). The mean before and after treatment BAI scores were 11.8 ± 6 and 1.33 ± 1.8 for Group 1 (P < 0.001), and 13.6 ± 8.3 and 2.9 ± 3.8 for Group 2 (P < 0.001). There was no significant difference between the before and after treatment DHI and BAI score differences of the two groups (P = 0.27, P = 0.43).

Conclusion

Canalith repositioning maneuvers (CRMs) should be the main treatment modality in the management of BPPV patients and adding on betahistine treatment to CRMs have no impact in the relieving of dizziness and anxiety symptoms.

Betahistine Prescribing Practices in England: An Analysis of Prescribing and National Spending Pre- and Post-BEMED Trial

OBJECTIVE

Betahistine has not been proven to be superior to placebo in the BEMED study, a multicenter, double-blind, randomized, placebo controlled trial. Our study aimed to establish the prescribing practices of clinicians in England in relation to betahistine and to assess if there has been any change in prescribing practices since the publication of the BEMED trial.

STUDY DESIGN

Retrospective study and clinician survey.

PATIENTS

All patients who were prescribed betahistine from primary care.

MAIN OUTCOME MEASURE

Total quantity of betahistine prescribed and total actual cost.

RESULTS

The average total monthly quantity prescribed was 11,143,253 tablets (range, 10,056,516-12,276,423). Prescribing did not decrease from the period before (January 2014-February 2016) to after (February 2016-February 2021) the publication of the BEMED trial, with the average monthly prescribing before publication being 11,294,848 tablets (range, 10,280,942- 12,276,423) and the average monthly prescribing after publication being 11,081,123 tablets (range, 10,056,516-11,915,707). The average actual monthly cost increased from the period before publication to after publication from a sum of £279,264.82 to a sum of £428,846.22. Most (90.5%) of the survey respondents prescribed betahistine for Menière's disease. Less than half (38.09%) prescribed betahistine for indications other than Menière's disease. Only 45.24% of the clinicians were aware of the results of the BEMED trial.

CONCLUSIONS

Knowledge of the BEMED trial among otology and neurotology subspecialists is lacking. The results of the BEMED have made no difference to prescribing practice, and in fact, the cost of the medication to the health bill has increased.

Starting point for improving the approach to vertigo in primary care

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a prevalent and disabling pathology. Its diagnosis and treatment according to clinical practice guidelines is carried out through canalicular repositioning maneuvers, but these maneuvers are not performed routinely in primary care consultations.

AIM

To analyse the baseline data from the VERTAP randomised community trial that evaluates whether a blended course is effective in improving the adherence of primary care physicians to clinical practice guidelines.

METHOD

Baseline data 2021.

SCOPE

20 primary healthcare centers with an assigned population of 514157.

OUTCOME VARIABLES

sex, age, diagnoses related to vertigo/dizziness, anti-vertigo medications prescribed, number of referrals to the otolaryngologist and neurologist, complementary examinations, and sick leave.

RESULTS

Vertigo/dizziness-related diagnoses totaled 21 359 cases, with a prevalence of 4.15%. Women made up 51.49% of cases. Median age was 52.00 (41.00, 65.00) years. Non-specific diagnoses totaled 18 617 (87.16%), including dizziness (n = 13 846, 64.83%), unspecified vestibular function disorder (n = 962, 4.50%), aural vertigo (n = 7, 0.03%), and other (n = 3802, 17.80%). Specific diagnoses totalled 2742 (12.84%), including BPPV (n = 1665, 7.80%), vestibular neuritis (n = 24, 0.11%), Menière's disease (n = 992, 4.64%), and central vertigo (n = 61, 0.29%). Anti-vertigo drugs prescribed included betahistine (n = 13 338, 62.45%), sulpiride (n = 3379, 15.82%), and dimenhydrinate (n = 20, 0.093%). Complementary examinations included computed tomography (n = 5704, 26.70%) and magnetic resonance (n = 604, 2.83%). One temporary disability for work (n = 1468, 6.87%); ≥2 temporary disability for work (n = 275, 1.29%).

CONCLUSION

The majority of diagnostic records related to vertigo/dizziness were non-specific (9 out of 10). The number of prescriptions for betahistine, and referrals, mainly to an otolaryngologist, are considerable and an avoidable expense. Better knowledge about vertigo/dizziness in care could improve the diagnostic and therapeutic accuracy of this pathology as well as the social and health costs it produces.

Efficacy of Epley's maneuver plus betahistine in the management of PC-BPPV: A systematic review and meta-analysis

BACKGROUND

To evaluate the efficacy of Epley's maneuver plus betahistine in the management of patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV).

METHODS

Electronic databases including PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang were searched from their inception to April, 2022. The effect size was analyzed by calculating the pooled risk ratio estimates of efficacy rate, recurrence rate, and standardized mean differences (SMD) of dizziness handicap inventory (DHI) score with a 95% confidence interval (CI). Sensitive analysis was performed simultaneously.

RESULTS

A total of 9 randomized controlled trials with 860 PC-BPPV patients were included in the meta-analysis, in which 432 were treated with Epley's maneuver plus betahistine, and 428 received Epley's maneuver alone. The meta-analysis revealed that Epley's maneuver plus betahistine significantly improved DHI score than Epley's maneuver alone (SMD = -0.61, 95% CI -0.96 to -0.26, P = .001). In addition, both Epley's maneuver plus betahistine and Epley's maneuver groups had comparable outcomes in efficacy rate and recurrence rate.

CONCLUSION

This meta-analysis shows that Epley's maneuver plus betahistine in PC-BPPV patients had favorable effects on DHI score.

Pharmacological interventions for prevention of weight gain in people with schizophrenia

BACKGROUND

Antipsychotic-induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic-induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem.

OBJECTIVES

To determine the effectiveness of pharmacological interventions for preventing antipsychotic-induced weight gain in people with schizophrenia.

SEARCH METHODS

The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia-like illnesses who use antipsychotic medications.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI.

MAIN RESULTS

Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta-analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low-certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD -4.03 kg, 95% CI -5.78 to -2.28; 4 studies, 131 participants; low-certainty evidence); and BMI increase (MD -1.63 kg/m2, 95% CI -2.96 to -0.29; 5 studies, 227 participants; low-certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD -1.32 kg, 95% CI -2.09 to -0.56; 3 studies, 248 participants; low-certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD -1.89 kg, 95% CI -3.31 to -0.47; 3 studies, 103 participants; low-certainty evidence; BMI: MD -0.66 kg/m2, 95% CI -1.05 to -0.26; 3 studies, 103 participants; low-certainty evidence). Topiramate did not appear effective in preventing weight gain (MD -4.82 kg, 95% CI -9.99 to 0.35; 3 studies, 168 participants; very low-certainty evidence). For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low-certainty evidence.

AUTHORS' CONCLUSIONS

There is low-certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain.

A comparative study of vestibular improvement and gastrointestinal effect of betahistine and gastrodin in mice

Betahistine and gastrodin are the first-line medications for vestibular disorders in clinical practice, nevertheless, their amelioration effects on vestibular dysfunctions still lack direct comparison and their unexpected extra-vestibular effects remain elusive. Recent clinical studies have indicated that both of them may have effects on the gastrointestinal (GI) tract. Therefore, we purposed to systematically compare both vestibular and GI effects induced by betahistine and gastrodin and tried to elucidate the mechanisms underlying their GI effects. Our results showed that betahistine and gastrodin indeed had similar therapeutic effects on vestibular-associated motor dysfunction induced by unilateral labyrinthectomy. However, betahistine reduced total GI motility with gastric hypomotility and colonic hypermotility, whereas gastrodin did not influence total GI motility with only slight colonic hypermotility. In addition, betahistine, at normal dosages, induced a slight injury of gastric mucosa. These GI effects may be due to the different effects of betahistine and gastrodin on substance P and vasoactive intestinal peptide secretion in stomach and/or colon, and agonistic/anatgonistic effects of betahistine on histamine H1 and H3 receptors expressed in GI mucosal cells and H3 receptors distributed on nerves within the myenteric and submucosal plexuses. Furthermore, treatment of betahistine and gastrodin had potential effects on gut microbiota composition, which could lead to changes in host-microbiota homeostasis in turn. These results demonstrate that gastrodin has a consistent improvement effect on vestibular functions compared with betahistine but less effect on GI functions and gut microbiota, suggesting that gastrodin may be more suitable for vestibular disease patients with GI dysfunction.

Analysis of the nystagmus characteristics of cupula diseases: A case report

INTRODUCTION

Clinically, there is a kind of patients with positional vertigo or dizziness, which occurs when they turn left or right, look down or up, lie down or sit up. With a long duration and varying frequency, it is not consistent with the manifestations of benign paroxysmal positional vertigo (BPPV). In addition, the persistent geotropic direction-changing positional nystagmus (PG-DCPN) was observed in a supine head-roll test.

PATIENT CONCERNS

With no apparent trigger for visual rotation and a sense of self instability, an 81-year-old female patient had suffered from vertigo for 3 days. The vertigo occurred every day, lasting several minutes each time, and associated with head movements and changes in body position. In a supine head-roll test, it appeared persistent geotropic direction-changing positional nystagmus for a long time, without latency, fatigability and in the presence of 3 zero planes.

DIAGNOSIS

Light cupula.

INTERVENTIONS

Difenidol hydrochloride 25 mg orally 3 times/day for 2 weeks and betahistine hydrochloride 12 mg orally 3 times/day for 1 month were administered.

OUTCOMES

After 1 month of treatment, the patient's vertigo symptoms disappeared. And in the supine head-roll test, the persistent geotropic direction-changing positional nystagmus disappeared.

CONCLUSION

We report the characteristics of nystagmus produced in a typical patient with light cupula during the supine head-roll test. After reviewing the relevant literatures, we believe that a simpler method can be used to identify canalolithiasis and cupula disease, to distinguish light and heavy cupula, and to determine the pathological semicircular canal to which the lesion belongs.

Clinical therapeutic effects of gastrodin in combination with betahistine on vertigo: A protocol for systematic review and meta-analysis

BACKGROUND

Vertigo is a well-known presenting complaint common in the main care offices as well as departments. It is also regarded as a symptom of vestibular dysfunction and has been expressed as a feeling of motion, specifically rotational motion. As patients grow older, vertigo also becomes a commonly presenting complaint. The current study will carry out a widespread systematic review to estimate clinical therapeutic effects of gastrodin in combination with betahistine on vertigo.

METHODS

We will systematically search different databases, including PubMed, EMBASE, Web of Science, the Cochrane Library, Chinese BioMedical Literature Database (CBM), China National Knowledge Infrastructure Database (CNKI), and WanFang to collect the randomised controlled studies that evaluate the efficiency of gastrodin and betahistine in treating patients with vertigo from their inception to November 2020. However, only studies in English or Chinese will be included. Two authors will independently perform selection, data extraction, and assessment of risk of bias for the included papers. Accordingly, any disagreements between the independent authors will be addressed via discussion or by consulting a third author when needful. Additionally, we will use RevMan 5.3 software to perform the data synthesis.

RESULTS

The efficiency of gastrodin and betahistine in treating patients with vertigo will be systematically evaluated.

CONCLUSIONS

The current study aims to stipulate more consistent substantiation to explore whether gastrodin combined with betahistine is more effective for the treatment of vertigo.

REGISTRATION NUMBER

DOI 10.17605/OSF.IO/HQTZA (https://osf.io/hqtza/).

Pharmacologic and surgical therapies for patients with Meniere's disease: A systematic review and network meta-analysis

BACKGROUND

Meniere's disease (MD) is a chronic condition of the inner ear consisting of symptoms that include vertigo attacks, fluctuating sensorineural hearing loss, tinnitus and aural fullness. Despite availability of various interventions, there is uncertainty surrounding their relative efficacy, thus making it difficult to select the appropriate treatments for MD. The objective of this systematic review was to assess the relative effects of the available pharmacologic and surgical interventions in patients with MD with regard to vertigo and other key patient outcomes based on data from randomized clinical trials (RCTs).

METHODS

Our published protocol registered with PROSPERO (CRD42019119129) provides details on eligibility criteria and methods. We searched various databases including MEDLINE, Embase and the Cochrane Library from inception to December 10th, 2018. Screening at citation and full-text levels and risk of bias assessment were performed by two independent reviewers in duplicate, with discrepancies resolved by consensus or third-party adjudication. Bayesian network meta-analyses (NMA) were performed for hearing change and vertigo control outcomes, along with pairwise meta-analyses for these and additional outcomes.

RESULTS

We identified 2,889 unique citations, that yielded 23 relevant publications describing 18 unique RCTs (n = 1,231 patients). Overall, risk-of bias appraisal suggested the evidence base to be at unclear or high risk of bias. Amongst pharmacologics, we constructed treatment networks of five intervention groups that included placebo, intratympanic (IT) gentamicin, oral high-dose betahistine, IT steroid and IT steroid plus high-dose betahistine for NMAs of hearing change (improvement or deterioration) and complete vertigo control. IT steroid plus high-dose betahistine was associated with the largest difference in hearing improvement compared to placebo, followed by high-dose betahistine and IT steroid (though 95% credible intervals failed to rule out the possibility of no difference), while IT gentamicin was worse than IT steroid. The NMA of complete vertigo control suggested IT gentamicin was associated with the highest probability of achieving better complete vertigo control compared to placebo, followed by IT steroid plus high-dose betahistine. Only two studies related to surgical interventions were found, and data suggested no statistically significant difference in hearing changes between endolymphatic duct blockage (EDB) versus endolymphatic sac decompression (ESD), and ESD with or without steroid injection. One trial reported that 96.5% of patients in EDB group compared to 37.5% of the patients in ESD group achieved complete vertigo control 24 months after surgery (p = 0.002).

CONCLUSION

To achieve both hearing preservation and vertigo control, the best treatment option among the pharmacologic interventions compared may be IT steroid plus high-dose betahistine, considering that IT gentamicin may have good performance to control vertigo but may be detrimental to hearing preservation with high cumulative dosage and short interval between injections. However, IT steroid plus high-dose betahistine has not been compared in head-to-head trials against other interventions except for IT steroid alone in one trial, thus future trials that compare it with other interventions will help establish comparative effectiveness with direct evidence.

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

Background and Objective

Vertigo derived from peripheral vestibular disorders is quite frequently encountered in daily clinical practice and can be a severely disabling symptom associated with substantial impairment of health-related quality of life for the affected patients. Betahistine, a structural analogue of histamine and presumably the most widely prescribed anti-vertigo drug worldwide, has previously been shown to be an effective and safe treatment for these patients. The objective of the present study was to evaluate whether the fixed combination of cinnarizine and dimenhydrinate (Arlevert^®) is non-inferior and thus a potentially useful alternative to betahistine dihydrochloride in the treatment of patients suffering from peripheral vestibular vertigo.

Methods

In this prospective, multicenter, double-blind, randomized, non-inferiority clinical trial, outpatients from 8 ENT clinics in Austria, Bulgaria, the Czech Republic and Russia were randomly assigned to receive three times daily one tablet of either the fixed combination cinnarizine 20 mg/dimenhydrinate 40 mg or betahistine dihydrochloride 16 mg for 4 weeks. Primary endpoint was the reduction of the mean vertigo score (MVS), a validated 12-item composite score defined as the mean of 6 vertigo symptoms (dystasia and walking unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, blackout) and 6 trigger factors for vertigo (change of position, bowing, getting up, driving by car/train, head movements, eye movement), after 4 weeks of therapy, as judged by the patient on a 5-point visual analogue scale (VAS). The non-inferiority margin was set to 0.3. Secondary outcomes included the patient’s and investigator’s judgment of global efficacy, the patient’s rating of impairment of daily activities, and safety/tolerability of the treatments.

Results

Three hundred and six patients (mean age 53.5 years, approximately 60% female) were enrolled and randomized to the fixed combination cinnarizine/dimenhydrinate (n = 152) or betahistine (n = 154) groups; 297 patients completed the study and 294 (146 and 148, respectively) were valid for the per-protocol analysis, which was used for the non-inferiority analysis. Treatment with cinnarizine/dimenhydrinate led to a stronger reduction of the MVS [least squares mean (LSM)] after 4-week therapy (primary endpoint) in comparison to betahistine (0.395 vs 0.488; difference: − 0.093, 95% CI − 0.180; − 0.007, p = 0.035); since the upper limit of the two-sided 95% confidence interval was not only below the non-inferiority margin of 0.3, but also entirely below 0, superiority of the fixed combination could be demonstrated. The combination preparation was also more effective after 1 week of therapy and received more favorable patient’s ratings on overall efficacy and impairment of daily activities. Both treatments were very well tolerated. Only 12 patients (3.92%) reported 13 non-serious adverse events; 2 cinnarizine/dimenhydrinate-treated patients discontinued the study prematurely due to adverse events as compared to 5 betahistine-treated patients.

Conclusion

The fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg was found to be not only non-inferior, but superior to betahistine 16 mg in the improvement of peripheral vestibular vertigo. Furthermore, taking into account a good and slightly favorable safety profile, the present study provides evidence that the fixed-combination preparation is a potent and even superior alternative to betahistine in the treatment of vertigo related to peripheral vestibular disorders.

Study Registration

EudraCT No. 2011-004025-27.

Approach to Ménière disease management

OBJECTIVE

To provide family physicians with an updated approach to the diagnosis and management of Ménière disease (MD), detailing the natural course of MD and describing how to initiate medical therapy while awaiting consultation with otolaryngology-head and neck surgery.

SOURCES OF INFORMATION

The approach is based on the authors' clinical practices and review articles from 1989 to 2018. Most of the cited studies provided level II or III evidence.

MAIN MESSAGE

Ménière disease is an uncommon disorder of the inner ear causing vertigo attacks with associated unilateral hearing loss, tinnitus, and aural fullness. It has a degenerative course that often results in permanent sensorineural hearing loss. On average, MD stabilizes with no further vestibular attacks by about 8 years after the onset of symptoms; however, this is highly variable. Vertigo symptoms can be controlled through a combination of dietary salt restriction, stress reduction, and medical therapy (betahistine, diuretics, or both). These can be initiated by family physicians before consultation with otolaryngology-head and neck surgery. Symptoms refractory to such strategies can be treated using nonablative, and occasionally ablative, therapies.

CONCLUSION

A thorough history is key to the approach to and management of MD and permits differentiating MD from other vestibular and nonvestibular conditions.

Effects of vestibular rehabilitation, with or without betahistine, on managing residual dizziness after successful repositioning manoeuvres in patients with benign paroxysmal positional vertigo: a protocol for a randomised controlled trial

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is recognised as the leading cause of peripheral vertigo in adults. The canalith repositioning procedure (CRP) can be used for effective treatment of BPPV. However, some patients experience residual dizziness (RD) even after successful CRP, resulting in a significant negative impact on their daily function and quality of life. Exercise-based vestibular rehabilitation (VR) has been proven as an effective method for managing dizziness and has been applied in patients with various vestibular disorders. However, the efficacy of VR to specifically target RD post-BPPV is unknown. This study aims to investigate the efficacy of VR, compared with betahistine or VR plus betahistine treatment, in the treatment of patients experiencing RD after successful CRP.

METHODS AND ANALYSIS

A randomised single-blinded controlled trial will be carried out to determine the efficacy of VR compared with betahistine or VR plus betahistine treatment in mitigating RD and improving balance function. Patients with BPPV who experience RD after successful CRP will be recruited. Participants will be randomised into one of three groups to receive VR, betahistine or VR plus betahistine. There will be 61 participants in each group. The primary outcomes will be changes in the patient's daily function as measured by the Vestibular Activities and Participation questionnaire and balance ability assessed by computerised dynamic posturography. The secondary outcomes will be dizziness-related handicap, otolith function and duration of RD symptoms. Outcome measures will be noted at baseline and at 2, 4 and 8 weeks post-randomisation. This study has the potential to reduce unnecessary anti-vertigo drug prescriptions and may lead to a general consensus regarding the use of VR as a first-line treatment for RD in patients with BPPV.

ETHICS AND DISSEMINATION

This trial received ethical approval from the Institutional Review Board of Eye and ENT Hospital of Fudan University (reference number 2017046). The study results will be disseminated via peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

NCT03624283; Pre-results.

Randomized trial of betahistine mesilate tablets as augmentation for oxcarbazepine and carbamazepine in treating vestibular paroxysmia

Background

Vestibular paroxysmia (VP) is a rare episodic peripheral vestibular disorder. This study was conducted to compare the efficacy and acceptability of carbamazepine (CBZ) plus betahistine mesilate tablets (BMT) (CBZ+BMT) and oxcarbazepine (OXC) plus BMT (OXC+BMT) in treating VP, and investigated whether the synergistic effect could be increased along with the increased dose of BMT.

Methods

VP patients were recruited and randomly assigned to receive CBZ+BMT or OXC+BMT. The doses of CBZ and OXC were set to 200 and 300 mg/time, twice daily, respectively. The doses of BMT were set to 12 and 18 mg/time, twice daily. Half of the patients in each group received BMT 12 mg/time and the other half received BMT 18 mg/time. The treatment was continued for 12 weeks. The vertigo frequency, vertigo score, vertigo duration, response rate, and drug-related side effects were analyzed.

Results

In total, 92 patients in the CBZ+BMT group and 93 patients in the OXC+BMT group completed this trial. After 12 weeks of treatment, the two groups had similar average vertigo frequency, average vertigo score, average vertigo duration, and response rate. But the incidence of side effects was significantly higher in the CBZ+BMT group than in the OXC+BMT group (p=0.04). Subgroup analysis found that patients receiving BMT (18 mg) had greater reductions in average vertigo frequency, average vertigo duration, and average vertigo score, and higher response rates than patients receiving BMT (12 mg).

Conclusion

These results demonstrated that OXC+BMT may be suitable as an alternative method in VP patients with CBZ hypersensitivity, and the synergistic effect could be increased along with the increased dose of BMT.

Efficacy of Betahistine by Patient-Reported Outcomes and its Tolerability Profile in Indian Patients with Vestibular Vertigo

OBJECTIVE

Patients with vestibular vertigo suffer from disabling symptoms which affect their quality of life. This article presents the efficacy and safety profile of betahistine hydrochloride in Indian patients suffering from vestibular vertigo (OSVaLD study).

METHODS

Study included patients suffering from vertigo, who were prescribed betahistine (48 mg/day) according to local label. Safety and efficacy populations of this study included 80 and 75 subjects respectively. The study included three visits: an initial baseline visit, and two follow-up visits (one month and three months [final visit] post-commencement of betahistine therapy). Efficacy was assessed by administering three patient-reported outcomes (PROs) namely, Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), and Medical Outcome Study Short Form-36 version2 (SF-36®v2). Safety assessment was made by reports of Suspected Adverse Drug Reactions (SADRs) which began during the study.

RESULTS

Mean changes in total DHI score for Indian efficacy population at follow-up and final visits were 31 and 44 points respectively. These changes indicated significant improvements in self-perceived impairment associated with vertigo. Similar improvements in quality of life were observed by HADS subscales (HADS-A and HADS-D) and SF-36®v2 summary scores (PCS [physical component summary] and MCS [mental component summary]). There was only one report of SADR in this study in a female subject receiving betahistine 16 mg t.i.d. This SADR was gastritis of mild severity and was probably not related to betahistine.

CONCLUSIONS

A significant number of vestibular vertigo patients reported fair degree of spontaneous recovery. Betahistine treatment improved quality of life, was safe and well-tolerated by Indian patients suffering from vertigo.

Hearing function after betahistine therapy in patients with Ménière's disease

Introduction

Objective

Methods

Results

Conclusion

A Two-Year Randomized Trial of Interventions to Decrease Stress Hormone Vasopressin Production in Patients with Meniere's Disease-A Pilot Study

Meniere's disease, a common inner ear condition, has an incidence of 15-50 per 100,000. Because mental/physical stress and subsequent increase in the stress hormone vasopressin supposedly trigger Meniere's disease, we set a pilot study to seek new therapeutic interventions, namely management of vasopressin secretion, to treat this disease. We enrolled 297 definite Meniere's patients from 2010 to 2012 in a randomized-controlled and open-label trial, assigning Group-I (control) traditional oral medication, Group-II abundant water intake, Group-III tympanic ventilation tubes and Group-IV sleeping in darkness. Two hundred sixty-three patients completed the planned 2-year-follow-up, which included assessment of vertigo, hearing, plasma vasopressin concentrations and changes in stress/psychological factors. At 2 years, vertigo was completely controlled in 54.3% of patients in Group-I, 81.4% in Group-II, 84.1% in Group-III, and 80.0% in Group-IV (statistically I < II = III = IV). Hearing was improved in 7.1% of patients in Group-I, 35.7% in Group-II, 34.9% in Group-III, and 31.7% in Group-IV (statistically I < II = III = IV). Plasma vasopressin concentrations decreased more in Groups-II, -III, and -IV than in Groups-I (statistically I < II = III = IV), although patients' stress/psychological factors had not changed. Physicians have focused on stress management for Meniere's disease. However, avoidance of stress is unrealistic for patients who live in demanding social environments. Our findings in this pilot study suggest that interventions to decrease vasopressin secretion by abundant water intake, tympanic ventilation tubes and sleeping in darkness is feasible in treating Meniere's disease, even though these therapies did not alter reported mental/physical stress levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01099046.

Betahistine for symptoms of vertigo

BACKGROUND

Vertigo is a symptom in which individuals experience a false sensation of movement. This type of dizziness is thought to originate in the inner ear labyrinth or its neural connections. It is a commonly experienced symptom and can cause significant problems with carrying out normal activities. Betahistine is a drug that may work by improving blood flow to the inner ear. This review examines whether betahistine is more effective than a placebo at treating symptoms of vertigo from different causes.

OBJECTIVES

To assess the effects of betahistine in patients with symptoms of vertigo from different causes.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. We also contacted manufacturers and researchers in the field. The date of the search was 21 September 2015.

SELECTION CRITERIA

We included randomised controlled trials of betahistine versus placebo in patients of any age with vertigo from any neurotological diagnosis in any settings.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcome was the proportion of patients with reduction in vertigo symptoms (considering together the intensity, frequency and duration those symptoms).

MAIN RESULTS

We included 17 studies, with a total of 1025 participants; 12 studies were published (567 patients) and five were unpublished (458 patients). Sixteen studies including 953 people compared betahistine with placebo. All studies with analysable data lasted three months or less. The majority were at high risk of bias, but in some the risk of bias was unclear. One study, at high risk of bias, included 72 people with benign paroxysmal positional vertigo (BPPV) and compared betahistine with placebo; all patients also had particle repositioning manoeuvres. The studies varied considerably in terms of types of participants, their diagnoses, the dose of betahistine and the length of time it was taken for, the study methods and the way any improvement in vertigo symptoms was measured. Using the GRADE system, we judged the quality of evidence overall to be low for two outcomes (proportion of patients with improvement and proportion with adverse events).Pooled data showed that the proportion of patients reporting an overall reduction in their vertigo symptoms was higher in the group treated with betahistine than the placebo group: risk ratio (RR) 1.30, 95% confidence interval (CI) 1.05 to 1.60; 606 participants; 11 studies). This result should be interpreted with caution as the test for statistical heterogeneity as measured by the I(2) value was high.Adverse effects (mostly gastrointestinal symptoms and headache) were common but medically serious events in the study were rare and isolated: there was no difference in the frequency of adverse effects between the betahistine and placebo groups, where the rates were 16% and 15% respectively (weighted values, RR 1.03, 95% CI 0.76 to 1.40; 819 participants; 12 studies).Sixteen per cent of patients from both the betahistine and the placebo groups withdrew (dropped out) from the studies (RR 0.96, 95% CI 0.65 to 1.42; 481 participants; eight studies).Three studies looked at objective vestibular function tests as an outcome; the numbers of participants were small, techniques of measurement very diverse and reporting details sparse, so analysis of this outcome was inconclusive.We looked for information on generic quality of life and falls, but none of the studies reported on these outcomes.

AUTHORS' CONCLUSIONS

Low quality evidence suggests that in patients suffering from vertigo from different causes there may be a positive effect of betahistine in terms of reduction in vertigo symptoms. Betahistine is generally well tolerated with a low risk of adverse events. Future research into the management of vertigo symptoms needs to use more rigorous methodology and include outcomes that matter to patients and their families.

Betahistine reduces postoperative nausea and vomiting after laparoscopic gynecological surgery

BACKGROUND

Patients undergoing laparoscopic gynecological surgery are at high risk of postoperative nausea and vomiting (PONV). We compared the antiemetic efficacy of ondansetron plus betahistine with that of ondansetron alone in this patient population.

METHODS

In this randomized, double-blinded study, 168 patients were randomly allocated to receive placebo (O group) or betahistine 18 mg (OB group) orally 3 hours before surgery and 24 hours thereafter. In both groups, ondansetron 4 mg was administered at the end of surgery and 8 mg were added to an intravenous patient-controlled analgesia (IV-PCA) fentanyl solution. The primary outcome was complete response (no PONV and no rescue antiemetics) during the first 48 hours after surgery. The severity of nausea, pain score, and adverse events were assessed.

RESULTS

The incidence of complete response was significantly higher in OB group than in O group (69% vs. 46%, P=0.004). The severity of nausea was lower in OB group than in O group during 30 minutes to 6 hours and 6 to 24 hours after surgery (P=0.001 and P<0.001). Pain score was similar between the groups. The incidence of dizziness was lower in OB group than in O group (13% vs. 40%, P < 0.001). Six patients (7%) in OB group and 15 patients (18%) in O group required early IV-PCA discontinuation, primarily because of PONV and/or dizziness (P=0.038).

CONCLUSIONS

Compared to ondansetron alone, ondansetron plus betahistine was more effective to prevent PONV and dizziness in high-risk patients undergoing laparoscopic gynecological surgery.

Hyperbaric oxygen therapy in tinnitus with normal hearing in association with combined treatment

Tinnitus is a phantom perception of sound in the absence of overt acoustic stimulation. The focus of our attention is a combined therapy of tinnitus. In this prospective study (2013-2014) we evaluated the data of normal-hearing patients with tinnitus treated with various treatment modalities. In Group 1 we evaluated the data of 84 patients/124 ears after six weeks of treatment with betahistine dihydrochloride (72 mg). In Group 2, we evaluated the data of 36 patients/ 55 ears unimproved from Group 1 who were then treated for six weeks with hyperbaric oxygen (HBO₂) therapy combined with gingko biloba extract (120 mg). In Group 1, tinnitus disappeared in 9.7%, alleviated in 18.5% and improved overall in 28.2%. Average intensity of tinnitus before/after treatment was 37 decibels (dB)/33 dB. Tinnitus intensities after treatment are statistically significantly lower (p = 0.001) than the values before treatment. In Group 2 tinnitus disappeared in 5.4%, 36.4% achieved alleviation, and 41.8% showed overall improvement. The average intensity of tinnitus before/after treatment was 41dB/ 38dB. The values of tinnitus intensity after combined therapy are statistically significantly lower (p = 0.046). We have shown that both methods treatment of tinnitus are statistically significant. HBO₂therapy was recommended for the general public.

Treatment of Meniere's disease with intratympanic dexamethazone plus high dosage of betahistine

PURPOSE

The aim of the present study was to assess if the combined therapy of intratympanic dexamethasone (ITD) and high dosage of betahistine (HDBH) is able to provide increased vertigo control compared to ITD alone in patients suffering from definite unilateral Meniere's disease (MD).

MATERIALS AND METHODS

Consecutive MD patients were enrolled and randomly divided in two groups, each comprising 33 cases. Group A received a combination of ITD and identical-appearing placebo pills while Group B received a combination of ITD and HDBH. ITD protocol consisted of three consecutive daily injections. HDBH comprised 144mg/day (48mg tid). The main outcome measures were: 1) vertigo class, pure tone average (PTA), speech discrimination score (SDS) and Functional Level Score (FLS) according to the American Academy of Otolaryngology-Head and Neck Surgery criteria; 2) complete and substantial vertigo control according to the Kaplan-Meier survival method.

RESULTS

Sixty two patients completed the 24-month follow-up. A complete vertigo control was achieved in 14 patients (44%) from Group A and in 22 patients (73.3%) from Group B, statistically significant (p=0.01). Complete vertigo relief is also significant according to the Kaplan-Meier method: p=0.027, log rank test. Substantial vertigo control was obtained in 21 patients (65.6%) in Group A and 27 patients (90%) in Group B. The difference is statistically significant, p=0.02. The difference is significant according to the Kaplan-Meier method: p=0.035, log rank test. No significant differences between hearing levels and tinnitus scores were demonstrated between the groups.

CONCLUSIONS

Our preliminary results demonstrate that complete and substantial vertigo control is significantly higher in patients treated with a combination of HDBH and ITD.

Use of betahistine in the treatment of peripheral vertigo

CONCLUSION

Clinical studies and meta-analyses demonstrated that betahistine is effective and safe in the treatment of Ménière's disease, BPPV (benign paroxysmal positional vertigo), vestibular neuronitis, and other types of peripheral vertigo.

OBJECTIVES

The goal of this paper is to review the pharmacological profile of betahistine and the evidence for its effectiveness and safety in the treatment of peripheral vertigo.

METHODS

Selection criteria for the publications on betahistine included randomized clinical trials that evaluated the effectiveness and safety of betahistine vs placebo or active control in the treatment of peripheral vertigo. Recent meta-analyses were also included. Databases searched included PubMed, the Cochrane Ear, Nose and Throat Disorders Group Trials Register, and ICTRP. The review also presents an update on the mechanisms of action, pharmacodynamics, and pharmacokinetics of betahistine.

RESULTS

Efficacy and safety of betahistine has been demonstrated in numerous clinical trials. The precise mechanism of action of betahistine is still not completely understood, but the clinical experience demonstrated the benefit of betahistine in different types of peripheral vertigo. In more than 40 years of clinical use, betahistine has shown an excellent safety profile with the usual dose range from 8-48 mg daily. According to clinical studies, betahistine 48 mg daily during 3 months is an effective and safe option for the treatment of peripheral vertigo.

Long-term evaluation of the treatment of Menière's disease with betahistine HCl

Long-term evaluation of patients treated continuously for a period of 12-14 years with betahistine HCl shows a success rates of more than 80%. Many of these patients had various other kinds of therapy before betahistine HCl treatment to no avail. It seems to us that betahistine HCl is only a basic long-term treatment which has no habituation and still is active in controlling Menière's disease even after a long-term period. Other drugs such as antihistamine, phenothiazines, vitamins and tranquilizers only produce a symptomatic treatment. Betahistine HCl produces no modification or effect on the evolution of deafness.

Efficacy of medical therapy in the prevention of residual dizziness after successful repositioning maneuvers for Benign Paroxysmal Positional Vertigo (BPPV)

OBJECTIVES

The aim of this study was to investigate the efficacy of trimetazidine, betahistine, and ginkgo biloba extract in the treatment of residual dizziness after successful repositioning maneuvers for benign paroxysmal positional vertigo.

METHODOLOGY

This was a randomized controlled clinical trial. Complete clinical data were analyzed from 100 patients (27 men and 73 women; mean age 52.16 ± 13.2 years, range 11-80 years) with BPPV who underwent succcessful repositioning maneuvers and then received betahistine, trimetazidine, gingko biloba extract, or no medication (n = 25 for each group) for 1 week. On days 1, 3, and 5 after the repositioning maneuver, scores obtained from the Dizziness Handicap Inventory (DHI) questionnaire were compared.

RESULTS

There were no statistically significant differences in the premedication DHI scores of patients with residual dizziness among the four groups (p > 0.005). After 3 and 5 days of treatment, the mean DHI scores of the groups receiving medication did not differ significantly from the the mean DHI score of the control group (p > 0.005).

CONCLUSIONS

Our study results suggest that betahistine, trimetazidine, and gingko biloba extract do not alleviate residual dizziness after successful repositioning maneuvers.

[Characteristics and drug analysis associated with vertigo disease in real world]

To explore the characteristics and influenced factors associated with the onset of vertigo disease, analysis of 3 719 cases of hospitalized patients with vertigo disease from the real world. Analysis the date of patients diagnosed with vertigo disease from the hospital information system of 19 grade-III class-A hospital from 2004 to 2011, include general information, the doctor's advice, other diseases combined, diagnostic information and the relationship with the onset of 24 solar terms, and the treatment drugs. The median age of hospitalized patients with vertigo disease was 59, the number of women (65.91%) was more than men (34.09%), manual workers (85.32%) were the majority career, most patients (81.63%) condition were general by the time they were hospital admission, patients more like admitted to neurologist (70.34%) when they first time to outpatient serves, hospitalization days were in 8-14 days (46.65%), 46.04% of the patients in the hospital total cost is in 5 000 RMB to 10 000 RMB, 73.86% of patients paid by National Health Medical Insurance. Hypertension (20.79%) was the most common underlying health problems, The most common syndromes was deficiency of liver-Yin and kidney-Yin(44. 21%) , followed by hyperactivity of liver-yang, disease of phlegm turbidity in mongolia and deficiency of Qi and blood. There were more deficiency syndrome and less excess syndrome. The highest rate of hospital admission solar terms in 2009 was the insects awaken throttle (5.21%), In 2010, the highest rate solar terms of hospital admission was the rain throttle (6.14%). The most frequently used traditional Chinese medicine was gastrodine injection (20.55%), the most frequently used western medicine for betahistine (10.19%), gastrodine injection was the most traditional Chinese medicine that combination with other western medicine. Hypertension was the most underlying health problems in the patients with vertigo disease in the real world, although the mental factors should also be attention. Liver was the most closely internal organs with vertigo, and solar terms in spring was the highest-frequency time. Gastrodine injection was the most commonly used traditional Chinese medicin in clinical to treat vertigo diserse, the therapeutic regimen combining with traditional Chinese and western medicine has more advantages. We should pay more attention to the guidance of Chinese medicine "syncretism between heaven and man", to keep up with the rhythm of change, adapt to the changes in the human body growth and decline of the Yin and Yang, by adopting the method of syndrome differentiation in traditional Chinese medicine to prevention and treatment vertigo disease.

[An efficacy comparison of betahistin, trimetazidine and ginkgo biloba extract in patients with tinnitus]

OBJECTIVES

This study aims to investigate the efficacy of trimetazidine, betahistine and ginkgo biloba extract in the treatment of tinnitus.

PATIENTS AND METHODS

Complete clinical data of 90 patients (48 males, 42 females; mean age 52.3±15.1 years; range 20 to 61 years) who received betahistine, trimetazidine and ginkgo biloba extract for three months were retrospectively analyzed. The patients were divided into three groups including 30 in each group according to treatments received. Pre-treatment and post-treatment scores of tinnitus disability questionnaire were compared statistically.

RESULTS

There was no statistically significant difference between pre-treatment scores of tinnitus disability questionnaire among all three groups (p>0.05), while there was a statistically significant difference among the groups following treatment (p=0.019, p<0.05). After a-three-month treatment, a decrease of 19.7±15.5 units in trimetazidine group, 12.2±12.7 units in betahistine group, and 3.80±5.9 units in ginkgo biloba extract group were found to be statistically significant, compared to the mean pretreatment tinnitus disability questionnaire scores (p=0.002, p<0.01).

CONCLUSION

Our study results suggest that trimetazidine, betahistin and ginkgo biloba extract reduce tinnitus symptoms. However, symptomatic relief can be mostly achieved with trimetazidine treatment.

Reducing antipsychotic-induced weight gain in schizophrenia: a double-blind placebo-controlled study of reboxetine-betahistine combination

RATIONALE

Combination treatment with reboxetine, a selective norepinephrine reuptake inhibitor, and betahistine, a histamine H1 receptor agonist/H3 antagonist, was developed to produce complementary action in CNS pathways regulating appetite and body weight. In the present placebo-controlled study, we evaluated whether a reboxetine-betahistine combination attenuates olanzapine-induced weight gain in schizophrenia patients.

METHOD

Forty-three inpatients with DSM-IV schizophrenic disorder participated in a randomized double-blind study. Reboxetine (4 mg/day) with betahistine (48 mg/day) (N = 29) or placebo (N = 14) was co-administered with olanzapine (10 mg/day) for 6 weeks. Mental status was assessed at baseline and endpoint with relevant rating scales. Intention-to-treat method was used for statistical analysis.

RESULTS

Seven patients in the study group and four in the placebo group discontinued the trial. At the end of the trial, patients in the olanzapine/reboxetine + betahistine group gained significantly less weight than those in the olanzapine/placebo group [2.02 ± 2.37 and 4.77 ± 3.16 kg, respectively; t = 2. 89, degrees of freedom (df) = 41, p = 0.006]. The weight-attenuating effect of this combination was twofold larger than the weight-attenuating effect previously demonstrated with reboxetine alone. Significantly fewer patients in the study group than in the comparison group increased their initial weight by >7 %, the cutoff for clinically significant weight gain [3/29 (10.3 %) and 6/14 (42.9 %), respectively; χ (2) = 6.03, df = 1, p = 0.014]. The reboxetine-betahistine combination was safe and well tolerated.

CONCLUSIONS

Reboxetine-betahistine combination produces a clinically meaningful attenuation of olanzapine-induced weight gain. These results justify direct comparison between the reboxetine-betahistine combination and reboxetine alone.

[Clinical effectiveness and safety of sanchi tong shu capsule in the treatment of aural vertigo: a multi-center randomized controlled clinical trial]

OBJECTIVE

To evaluate the clinical effectiveness and safety of Sanchi Tong Shu capsule in the treatment of common aural vertigo.

METHOD

A multi-center randomized controlled trial was designed to study 206 vertigo patients who were randomly allocated into one of the two groups. One group was treated with Sanchi Tong Shu capsule for 14 days, another group was treated with betahistine mesilate tablets for 14 days.

RESULT

The clinical effectiveness rates of the two groups were 84.86% and 90.92% respectively according to FAS analysis and 84.76%, 90.92% respectively according to PPS analysis. No statistic significance difference was found between the two groups (P > 0.05). After 14 days treatment, total DHI and all the subsection (including body, emotion and function) scores of the two groups were all decreased compared with treatment before (P < 0.01). Compared the difference value of the total DHI and subsection scores before and after treatment, the two groups have no difference (P > 0.05). The adverse effective rate of the two groups were 3.29% and 7.84% respectively and there was no statistic difference between the two groups (P > 0.05).

CONCLUSION

Sanchi Tong Shu capsule is a safe and effective drug for the treatment of common aural vertigo.

Meniere's disease: an evidence based approach to assessment and management

Menière's disease (MD) is frequently over-diagnosed in both primary and secondary care. This is unfortunate given the significant medical and social implications of such a diagnosis. Difficulties may arise in differentiating the patient with true MD from those individuals with less clearly defined disorders of cochleo-vestibular function. In this review, we suggest a practical evidence based approach to assessment and management of the patient with MD.

[Treatment of vestibular vertigo and Ménière syndrome in outpatient clinics]

An aim of this study was to assess clinical efficacy and tolerability of tagista in the symptomatic treatment of vestibular vertigo and Ménière syndrome. Thirty-two patients, 16 women and 16 men, aged from 25 to 67 years, were examined. Vertigo was caused by chronic brain ischemia in 17 cases and by the disturbance of blood circulation in the vertebral-basilar system in 14 patients with osteochondrosis of cervical spine. One patient was diagnosed with Ménière syndrome. Tagista was used in dose 24 mg twice a day during 4 weeks in the combination with standard treatment, exercise therapy and stability training. The results revealed a statistically significant effect of the drug on main symptoms (frequency, duration and intensity of vertigo attacks etc) and its good tolerability that allowed to recommend the drug in neurological practice.

[Vertigo: patient management tactics]

To avoid serious causes of dizziness and establishing preliminary diagnosis is usually enough sighting history taking and physical examination of the patient. Great importance is self-presenting patients with complaints of dizziness. In recent years, for treatment of various types vestybulopatiy, but also for the prevention of attacks, successfully used betahistyn hydrochloride, which improves the quality of care and well-being of the patient.

[Betahistine in the treatment of vestibular and coordination disturbances in multiple sclerosis]

We present the results of the efficacy trial of betahistine (Vestibo) based on the complex clinical/instrumental examination (stabilometric, vestibulometric) in 40 patients with multiple sclerosis of different severity of vestibular and coordination dysfunction. We demonstrated the clinical efficacy and safety of using this drug as one of the areas of symptomatic therapy in treatment vestibular and coordination disturbances in multiple sclerosis.

[Vestibular disorders in patients with otosclerosis: prevalence, diagnostic and therapeutic options]

A total of 177 patients with otosclerosis were selected for this study. Vestibular disorders were diagnosed in 40 (22.6%) of them. The patients were allocated to 2 groups comprising 11 and 18 subjects respectively. Patients of group 1 were given surgical treatment during the current hospitalization. Patients of group 2 were treated by conservative therapy following stapedoplasty performed 1 year or more earlier. The study included analysis of vestibular symptoms and evaluation of clinical effectiveness of the combined treatment in the form of therapy with betahistine dihydrochloride (betaserk) during 2 months and a course of 10-12 sessions of game exercises at a stabilographic complex. The patients of both groups enjoyed reduced severity of subjective and objective vestibular symptoms and statistically significant improvement of the equilibrium function assessed from statokinesigrams. It is concluded that combined vestibuloadaptive therapy is an effective method of preparation for stapedoplasty and correction of postoperative complications.

Efficacy of a home-based exercise program on benign paroxysmal positional vertigo compared with betahistine

OBJECTIVE

To determine the efficacy of a home-based exercise program by comparing it with betahistine in patients with benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective, randomized, controlled study.

SETTING

Outpatient clinic of a university hospital.

PATIENTS

Thirty-eight patients (10 males, 28 females; mean age 46 +/- 13 years) diagnosed as having BPPV.

INTERVENTIONS

Patients were randomly assigned to either an exercise or a medication group. In the medication group, betahistine was prescribed at 24 mg/d for 1 month. The exercise group was required to perform Cawthorne-Cooksey exercises six times/day for 4 weeks.

MAIN OUTCOME MEASURES

The Vertigo, Dizziness, Imbalance Questionnaire (VDI), which consists of two subscales, the VDI symptom subscale (VDI-ss) and the VDI health-related quality of life (VDI-HRQoL) subscale, and the Vertigo Symptom Scale (VSS) were used for assessment at the beginning of the study and after 2 months.

RESULTS

The mean scores of the two components of the VDI and the VSS decreased in the exercise group by the fourth week. In the medication group, VSI mean scores, VDIss mean scores, and VSS mean scores decreased in the second week and VDI-HRQoL mean scores decreased in the fourth week. However, there were no significant differences between baseline and week 8. There were significant differences between groups regarding the change in the mean scores of the VDI (p = .001) and the VSS (p = .001) at the end of the study in favour of the exercise group.

CONCLUSIONS

Exercise was found to be a better treatment choice than medication and may be preferable for patients with persistent or chronic vertigo.

Treatment of vertebrobasilar insufficiency--associated vertigo with a fixed combination of cinnarizine and dimenhydrinate

Thirty-seven patients suffering from vertigo associated with vertebrobasilar insufficiency participated in our prospective, single-center, double-blind, comparative study. Patients were randomly allocated to treatment with placebo; betahistine (12 mg betahistine dimesylate, one tablet three times daily); or the fixed combination of 20 mg cinnarizine and 40 mg dimenhydrinate (one tablet three times daily) for 4 weeks. The primary efficacy end point was the decrease of the mean vertigo score (S(M)), which was based on the patients' assessments of 12 individual vertigo symptoms after 4 weeks of treatment. Patients treated with the fixed combination showed significantly greater reductions of S(M) as compared to patients receiving placebo (p < .001) or the reference therapy betahistine (p < .01). The vestibulospinal parameter lateral sway (Unterberger's test) improved to a significantly greater extent in patients taking the fixed combination as compared to those receiving placebo (p < .001). No serious adverse event was reported in any therapy group. The tolerability of the fixed combination was judged as very good or good by 91% (betahistine, 73%; placebo, 82%). In conclusion, the fixed combination proved to be statistically more effective than the common antivertiginous drug betahistine in reducing vertebrobasilar insufficiency-associated vertigo symptoms.

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.

Multimodal therapy for chronic tinnitus

From 2001 to 2006, we performed a retrospective study of patients suffering from chronic unilateral or bilateral tinnitus that was previously ineffectively treated by oral drugs [betahistine (Betaserc), extract of Ginkgo biloba (EGb 761), tanakan (Tebokan), and cinnarizine-dimenhydrinate (Arlevert), singly or in combination]. We divided 150 tinnitus patients (80 men, 70 women) into seven treatment groups. Treatments consisted of application of intravenous pentoxifylline, lidocaine, or vinpocetine (Cavinton) and combination of these agents with physiotherapy and soft laser. Mean duration (+/- standard deviation) of tinnitus in these patients was 7.4 +/- 6.0 years; their mean age was 55.6 +/- 12.5 years. The aim of our study was to compare treatment modalities and define their effectiveness for tinnitus relief. The most effective treatment was defined as a combination of Cavinton and physiotherapy. We evaluated pure lidocaine infusion therapy as ineffective. None of the treatment modalities had an objective correlate of improvement, though improvement was reported by a visual analog scale.

Optimizing the pharmacological component of integrated balance therapy

Summary

Drug treatment is an important option for the treatment of peripheral vestibular diseases.

Aim

To identify the drug component associated with optimal integrated balance therapy (IBT) for Ménière's disease or other peripheral vestibular disorders.

Materials and Methods

Analysis of a series of patients with Ménière's disease patients or patients with other peripheral vestibular disorders that received IBT involving either no medication or betahistine, cinnarizine, clonazepam, flunarizine or Ginkgo biloba during 120 days.

Results

In Ménière's disease, significant differences were observed for all drug therapies (60 days) versus no medication; betahistine was significantly more effective than all other drugs at 60 and 120 days. For non-Ménière's disorders, significant differences were observed among betahistine, cinnarizine, clonazepam and flunarizine and no medication after 60 days; all drug therapies were significantly more effective than no medication after 120 days; betahistine, cinnarizine or clonazepam were equally effective and betahistine was more effective than flunarizine and EGb 761. All treatment options were well tolerated.

Conclusions

Drug therapies were more effective than no medication in the IBT for patients with Ménière's disease or other peripheral vestibular disorders. Betahistine was the most effective medication for patients with Ménière's disease and was as effective as cinnarizine and clonazepam for other peripheral vestibular disorders.

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.

Reversible sensorineural hearing loss in a girl with Kawasaki disease

Kawasaki disease is an acute, self-limited vasculitis of infants and children that is now the most common cause of acquired heart disease in the pediatric age group in the United States and Japan. This report presents a case of classic Kawasaki disease with reversible sensorineural hearing loss that was treated with steroid. In conclusion, Kawasaki disease caregivers must be aware of possible sensorineural hearing loss, which is reversible by early intervention and thus improves quality of life.

[Frequently occurring forms of dizziness and their treatment]

Dizziness is not a unique clinical picture, but rather is the unspecific symptom of numerous diseases. Dizziness always develops when the real incoming vestibular, visual and somatosensory information contradict each other and the expected input signals. Disorders of the vestibular apparatus are the most frequent cause of dizziness; in contrast, cervicogenic causes play a secondary role. Dizziness syndromes usually have a favourable prognosis and can be successfully treated.

Menière's disease

INTRODUCTION

Menière's disease causes recurrent vertigo, hearing loss, tinnitus, and fullness or pressure in the ear, which mainly affects adults aged 40-60 years. Menière's disease is at first progressive but fluctuating, and episodes can occur in clusters. Vertigo usually resolves but hearing deteriorates, and symptoms other than hearing loss and tinnitus usually improve regardless of treatment.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for acute attacks of Menière's disease; and of interventions to prevent attacks and delay disease progression of Menière's disease? We searched: Medline, Embase, The Cochrane Library and other important databases up to January 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 17 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: anticholinergics, benzodiazepines, betahistine, cinnarizine, dietary modification, diuretics, phenothiazines, psychological support, trimetazidine, vestibular rehabilitation.