A Pharmacist's Guide to Meniere's Disease

Most Ménière’s patients in the United States are undiagnosed. In fact, there may be as many as 5 undiagnosed patients for every known case.¹

Symptoms

Vertigo can last hours at a time and poor balance may persist afterward. Hearing loss tends to be one-sided at first, may remit and recur, and some patients will develop progressive, severe, permanent hearing loss. Continuous low-pitched tinnitus often accompanies the hearing loss. A sensation of fullness in the ears develops shortly before, at the onset, or during episodes.²

At episode onset, patients may suffer from sudden “drop attacks,” which are periods of strong sensation of directional tilting causing patients to overcompensate and fall in the other direction.

Providers should counsel patients to avoid driving or pull over if an episode is impending.

Fluid build-up in the inner ear (endolymph) precipitates the disease episodes and contributes to progressive hearing loss. Increased semicircular canal pressure impacts balance and fluid build-up in the cochlea, causes hearing loss. Patients are often unaware of the initial cause of their disease. The most common causes include genetics, trauma, and viral illnesses (eg, common colds, measles, or mumps). Episodes may be clustered, predictable and periodic, or years apart.

Ménière ’s disease is likely related to migraines in many patients because both are often inherited and share triggers, and some Ménière ’s patients experience aura, photophobia, and headache during episodes.³ A sizable minority of providers call migraines with Ménière’s-like symptoms “migrainous vertigo.”

Episode Triggers and Prevention

Salty foods, caffeine, nicotine, and stress are the most common dietary and lifestyle triggers.⁴ Smoking cessation is particularly important in this population. Pharmacists should remind smokers with Ménière ’s disease that quitting will improve disease control. Low sodium hypertension-directed diets (eg, using DASH instead of salt) aid Ménière ’s disease control. Sodium consumption below 2000 mg per day will manage most patients’ symptoms, and a 1500 mg target is effective for almost everyone.² Alcohol, caffeine, and smoking reduction or cessation, as well as stress relief, are all healthful overall lifestyle interventions.

Oral Treatment

The most commonly used maintenance medications for Ménière’s disease are diuretics, such as Diamox Sequels (acetazolamide extended-release capsules) and Dyazide (triamterene/HCTZ).² These medications relieve the inner ear fluid build-up thereby reducing vertigo frequency and avoiding hearing loss progression. Acetazolamide (a carbonic anhydrase inhibitor) alkalinizes urine, encourages kidney stone formation, and increases ammonia reabsorption and hypokalemia risk.⁵ The usual counseling points of Dyazide for hypertension apply to its use in Ménière’s disease. Little evidence exists investigating similar regimens. The single double-blinded cross-over study supporting Dyazide found no impact on hearing loss, but patients expressed an unspecified preference over placebo.⁶ Loop diuretics are less favored because of their ototoxic effects.

Providers often recommend or prescribe meclizine (OTC Bonine and prescription Antivert) to control vertigo as needed. Dramamine is less effective, but patients may prefer it to Bonine. Bonine “motion sickness only” labeling and Antivert are FDA approved for vertigo. A patient may use 12.5 mg to 50 mg up to 3 times daily. The reasoning behind this labeling differences is from the possibility for serious causes of vertigo (eg, stroke or ototoxin consumption).⁷ Transient ischemic attacks can present as periodic dizziness and headache for months prior to a larger stroke. This presentation is difficult to differentiate from combined Ménière’s disease with migraine. Pharmacists should recommend provider consultation if a patient wants to use Bonine for vertigo without a prescriber’s approval.

Small doses of diazepam or lorazepam, promethazine (oral or rectal), and dexamethasone are used infrequently for treatment-resistant vertigo.^1,2 Benzodiazepines are most effective for patients triggered by stress. Promethazine treats vertigo-induced nausea. The rectal suppository formulation has lower bioavailability and slower absorption than the oral syrup, so prescribers should reserve it for patients unable to take medications orally.⁸ Oral dexamethasone can reduce inner ear swelling and provide symptomatic relief.

Injectable Treatment

Some patients without relief may elect for in-office injections of gentamicin or dexamethasone into the middle ear (then absorbed into the inner ear).⁹ Gentamicin, as an ototoxic aminoglycoside, deadens the vestibular system of the injected ear. Gentamicin eliminates vertigo in 70% of patients and causes permanent deafness in 30% of patients. Steroids, like dexamethasone, provide temporary relief via their anti-inflammatory effects without ototoxicity.²

Complementary and Alternative Medicines

Patients have tried tai chi, positive pressure, acupuncture, homeopathy, and herbals such as gingko biloba, niacin, or ginger root for symptom relief.¹⁰ Tai chi has promise for Ménière’s by reducing stress (a trigger shared with hypertension and migraines). A Cochrane Database systematic review of 5 randomized controlled trials found positive pressure devices (eg, the Meniett device) provide no vertigo relief and may worsen hearing loss.¹¹ English-language literature concerning acupuncture is scant, but one study of 34 patients found 1 to 3 sessions of acupuncture eliminated vertigo and arrested hearing loss.¹²

Homeopathic vertigoheel contains (gamma aminobutyric acid) GABAergic compounds and nicotine receptor inhibitors. Cocculus indicus and Conium maculatum, respectively, cause these effects. Salicylicum acidum, natrum salicylicum nux vomica, and chenopodium are 3 other studied homeopathic regimens with positive results. Commonly used herbal medicines used across the world include vinpocetine, valerian, ginger root, and Gingko biloba. Vinpocetine dilates cerebral blood vessels, valerian acts like a benzodiazepine, ginger reduces nausea, and Gingko biloba is anti-ischemic.¹² Gingko is the most studied of these herbals, but it increases bleeding risk, the optimal dose is uncertain, and efficacy is variable.

Conclusion

Most patients affected by Ménière’s disease are unaware that their vertigo, hearing loss, tinnitus, and sensation of ear fullness are a medical syndrome. Symptom control curbs disease-related disability development, and prompt control can delay or prevent hearing loss and physical falls. The goal of care is to reduce episode frequency and severity, hearing loss, and dizziness-related disability.

References

• Meniere’s disease. Medscape website. http://www.medscape.com/viewarticle/509085. Accessed November 20, 2016.

• Center for Hearing and Balance. Ménière’s disease. Mount Sinai Hospital. website. mountsinai.org/patient-care/service-areas/ent/areas-of-care/hearing-and-balance/vertigo-and-balance-disorders/menieres-disease. Accessed November 20, 2016.

• Ménière disease. MedlinePlus website. medlineplus.gov/ency/article/000702.htm. Updated August 13, 2015. Accessed November 20, 2016.

• Ménière’s diseases. Johns Hopkins Medicine website. hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/conditions/menieres_diseases.html. Accessed November 20, 2016.

• National Institutes of Health. Diamox Sequels- acetazolamide capsule, extended release. DailyMed website. dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=74e47451-2bc8-496e-88ad-c10002ee8e22 . Updated December 7, 2015. Accessed November 21, 2016.

• van Deelen GW, Huizing EH. Use of a diuretic (Dyazide) in the treatment of Ménière’s disease. A double-blind cross-over placebo-controlled study. ORL J Otorhinolaryngol Relat Spec. 1986;48(5):287-292.

• Mayo Clinic Staff. Ménière’s disease. Mayo Clinic website. mayoclinic.org/diseasesconditions/menieres-disease/basics/treatment/con-20028251. Updated November 26, 2016. Accessed November 20, 2016.

• Strenkoski-Nix LC, Ermer J, Decleene S, Cevallos W, Mayer PR. Pharmacokinetics of promethazine hydrochloride after administration of rectal suppositories and oral syrup to healthy subjects. Am J Health Syst Pharm. 2000;57(16):1499-1505.

• National Institutes of Health. Ménière’s Disease. National Institute of Deafness and Other Communication Disorders website. nidcd.nih.gov/health/menieres-disease. Published July 2010. Accessed November 20, 2016.

• van Sonsbeek S, Pullens B, van Benthem PP. Positive pressure therapy for Ménière's disease or syndrome. Cochrane Database Syst Rev. 2015;10(3):CD008419. doi: 10.1002/14651858.CD008419.pub2.

• Steinberger A, Pansini M. The treatment of Meniere's disease by acupuncture. Am J Chin Med. 1983;11(1-4):102-105.

• Papesch M. Complementary and alternative treatments for Ménière’s disease. ENT Care website. entcare.co.uk/treatments_in_menieres_disease.html. Published June 2005. Accessed November 20, 2016.