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

Treatment of Menière's disease: a scoping review of the current evidence

PURPOSE

The management of unilateral Menière's disease (MD) in adult patients remains contentious, with various therapeutic options proposed but no established gold standard. This scoping review aims to evaluate the current treatment options for unilateral MD, identifying challenges in management and providing guidance for ENT physicians in selecting effective therapies.

METHODS

A comprehensive literature search of the MEDLINE and Embase databases was conducted without date restrictions, assessing various treatment modalities for MD. Randomized controlled trials (RCTs) were selected to ensure the highest quality of evidence was reviewed.

RESULTS

Thirty-four RCTs met the inclusion criteria. The current evidence base encompasses dietary interventions, systemic drug therapy, intratympanic treatments, positive pressure therapy, low-level laser therapy, and non-destructive surgical techniques. However, the evidence supporting these treatments is limited and inconsistent. Notably, none of the RCTs considered the heterogeneity of MD patient populations, which may explain the variability in study results.

CONCLUSION

This review highlights the limited evidence supporting current treatments for unilateral MD, emphasizing the need for high-quality, placebo-controlled trials. Future research should incorporate biomarker-based stratification, large patient cohorts, standardized outcome measures, and long follow-up periods to enhance the consistency and comparability of findings.

Developing a core outcome set for Menière's disease trials, the COSMED study: a scoping review on outcomes used in existing trials

Introduction

Menière's disease (MD) is an inner ear disorder characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. As of yet, the etiology of MD remains unknown, which contributes to the lack of an evidence-based treatment. Outcomes and outcome measurement instruments (OMIs) used in trials assessing the effectiveness of potential MD treatment are randomly selected due to the absence of established guidelines on this matter. The objective of this review is to give an overview of the outcome domains, outcomes and OMIs used in randomized controlled trials (RCTs) evaluating treatment effects in MD to 2024. This will be the first step of developing a Core Outcome Set (COS) for MD trials.

Methods

A literature search of the PubMed, Embase and Cochrane library databases was conducted from inception to November 2024. All RCTs on the treatment effect of various therapies for patients suffering from MD were included. Among other details, we extracted and analyzed all outcome domains, outcomes, and OMIs used in these RCTs.

Results

A total of 76 RCTs were included, revealing a diverse range of outcomes and OMIs used across the included studies. Outcome domains encompassed dizziness, hearing, tinnitus, aural fullness, quality of life (QoL) and other. Outcomes used most frequently included: the severity of vertigo attacks, the number of vertigo attacks, vestibular function, hearing loss, severity of hearing loss, QoL related to dizziness, and Qol related to tinnitus. The latter two were most commonly measured with the Dizziness Handicap Inventory (DHI), the Functional Level Scale (FLS) and the Tinnitus Handicap Inventory (THI) respectively. For the other outcomes, there was little uniformity in the use of OMIs. Moreover, there was a notable lack of validated OMIs used in the included RCTs.

Conclusion

This scoping review highlights the need for standardizing outcome selection for RCTs focusing on the treatment of MD. In this first step of developing a Core Outcome Set for MD, we identified a potential list of outcomes to be used in the next steps of 'the Core Outcome Set for Menière's Disease (COSMED)' study.

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.

Betahistine in the Treatment of Peripheral Vestibular Vertigo: Results of a Real-Life Study in Primary Care

The present research was carried out with the objective to establish the clinical effect and safety of betahistine (48 mg daily), for the management of peripheral vestibular vertigo, in patients treated by primary care physicians in Colombia. An observational prospective cohort study was conducted including patients older than 15 years with clinical diagnosis of peripheral vestibular vertigo who were candidates to be treated with betahistine (48 mg daily). A sample size of 150 individuals was calculated, and weekly follow-ups were planned for 12 weeks. Rotatory movement sensation, loss of balance, and global improvement scale from 0 to 100 points were evaluated. Complete improvement was defined when the patient reached a level of 100 points. We calculated average weekly improvement, cumulative incidence of complete improvement, incidence rate of complete improvement, and the probability of complete improvement as a function of time. After the first week, the average improvement was 56.6 points (95% confidence interval [CI]: 50.4-62.7). At the end of week 12, it was 89.3 points (95% CI: 86.5-92.2). Sixty-one percent of the patients had achieved complete improvement at the end of the second week. After the sixth week, the percentage of cumulative improvement was 72%, and after 12 weeks of follow-up, the cumulative incidence of complete improvement was 73% (95% CI: 65%-80%). Based on the follow-up times, a complete improvement incidence rate of 16 cases per 100 people/week was calculated (95% CI: 13-19). We concluded that Betahistine (48 mg daily) has a positive effect, controlling the symptoms associated with benign paroxysmal vertigo, with an adequate safety profile.

Effectiveness of betahistine (48 mg/day) in patients with vestibular vertigo during routine practice: The VIRTUOSO study

Background

Vestibular vertigo is associated with substantially reduced quality of life. Betahistine is effective in improving vertigo-associated symptoms, with longer treatment periods leading to greater improvements; however, it is not known whether these effects persist after treatment cessation.

Methods

VIRTUOSO was a prospective, multinational, non-comparative, post-marketing observational programme investigating the effectiveness of betahistine (48 mg/day) and the course of vertigo after the discontinuation of treatment. Patients with vestibular vertigo who were prescribed 48 mg/day betahistine were enrolled in Russia and Ukraine. Treatment duration was up to 2 months, and patients were followed up for 2 months after discontinuation of betahistine. Efficacy endpoints included clinical response (assessed by change in vertigo severity), monthly attack frequency, and physician and patient grading of overall clinical response and improvement of vertigo-associated symptoms.

Results

Overall, 309 patients were enrolled and 305 completed the study. Clinical response was rated as good, very good or excellent in 74.1% of patients at end of treatment, with vertigo severity significantly decreased from baseline (p < 0.001). Monthly vertigo attack frequency decreased significantly during the 2 months of treatment (p < 0.001 from baseline) and further decreased during the 2-month follow-up (p < 0.001 from end of treatment). Overall, clinical response was graded as good or excellent by 94.4% of physicians and 95.4% of patients. Clinical improvement was considered either good or excellent by 82.6–90.5% of physicians and patients for nausea, vomiting and faintness. Only one adverse event was reported, with no serious adverse events.

Conclusion

Our findings suggest that betahistine (48 mg/day) therapy is effective in treating vertigo in routine clinical settings. The observed effects persisted for 2 months after treatment cessation, suggesting that betahistine may facilitate lasting vestibular compensation.

An LC-MS/MS assay for the quantitative determination of 2-pyridyl acetic acid, a major metabolite and key surrogate for betahistine, using low-volume human K2 EDTA plasma

Betahistine is widely used for the treatment of vertigo. Owing to first-pass metabolism, 2-pyridyl acetic acid (2PAA, major metabolite of betahistine) was considered as surrogate for quantitation. A specific and sensitive LC-MS/MS method was developed and validated for quantitation of 2PAA using turbo-ion spray in a positive ion mode. A solid-phase extraction was employed for the extraction of 2PAA and 2PAA d₆ (IS) from human plasma. Chromatographic separation of analytes was achieved using an ACE CN, 5 μm (50 × 4.6 mm) column with a gradient mobile phase comprising acetonitrile-methanol (90:10% v/v) and 0.7% v/v formic acid in 0.5 mm ammonium trifluoroacetate in purified water (100% v/v). The retention times of 1.15 and 1.17 min for 2PAA and internal standard, respectively, were achieved. Quantitation of 2PAA and internal standard was achieved by monitoring multiple reaction monitoring transition pairs (m/z 138.1 to m/z 92.0 and m/z 142.1 to m/z 96.1, respectively). The developed method was validated for various parameters. The calibration curves of 2PAA showed linearity from 5.0 to 1500 ng/mL, with a lower limit of quantitation of 5.0 ng/mL. The bias and precision for inter- and intra-batch assays were <10%. The developed method was used to support clinical sample analysis.

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.

Effect of hyperinsulinism on sensorineural hearing impairment in Ménière's disease: a cohort study

OBJECTIVE

To compare the degree of sensorineural hearing loss in patients with Ménière's disease (MD) with and without hyperinsulinism by different methods of assessment.

STUDY DESIGN

Historical cohort study.

SETTING

Ménière's Disease Care and Research Clinics of Hospital de Clinicas de Porto Alegre, a tertiary care university hospital in Southern Brazil.

PATIENTS

Patients with a definite diagnosis of MD based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines.

INTERVENTION

Patients were assessed by glucose overload tests (5-h glucose and insulin curves) and under baseline physiological conditions (Homeostasis Model Assessment/Insulin Resistance [HOMA-IR], Quantitative Insulin Sensitivity Check Index [QUICKI], and glucose/insulin ratio). These patients underwent annual pure-tone audiometry and were analyzed using 4-tone average (FTA), that is, arithmetic mean of 500, 1,000, 2,000, and 3,000 Hz, during the third, fourth, and fifth years of disease progression.

MAIN OUTCOME MEASURE

Hearing loss assessed by FTA and classified in Stages I to IV (AAO-HNS).

RESULTS

Forty-nine (76.6%) patients were defined as hyperinsulinemic and 15 (23.4%) as normoinsulinemic. Impairment on FTA was higher in the hyperinsulinemic group (52.04 ± 17.5 versus 39.75 ± 9.20, p = 0.027) when assessed by the 5-hour insulin curve. Hyperinsulinemic subjects were 3.5 times more likely to develop hearing damage greater than 40 dB (i.e., Stages III and IV) than normoinsulinemic subjects (OR = 3.52; 95% CI, 1.05-11.76). A moderate correlation between the insulin curve and the HOMA-IR was found (r = 0.524, p = 0.001).

CONCLUSION

Hyperinsulinism in MD is associated with greater clinical hearing damage.