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Hashimoto M, Koizuka I, Yamashita H, Suzuki M, Omori K, Origasa H, Takeda N, Shojaku H. Diagnostic and therapeutic strategies for vestibular neuritis of the Japan Society for Equilibrium Research. Auris Nasus Larynx 2024; 51:31-37. [PMID: 36581537 DOI: 10.1016/j.anl.2022.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To provide diagnostic and therapeutic strategies for vestibular neuritis in accordance with the Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021. METHODS The Committee for Clinical Practice Guidelines for Vestibular Neuritis was entrusted with a review of the relevant scientific literature on the above topic. Clinical Questions (CQs) concerning the treatment of vestibular neuritis were produced, and a search of the literature was conducted to identify studies related to the CQs. The recommendations were based on the literature review and the expert opinion of a subcommittee. RESULTS We proposed the diagnostic criteria for vestibular neuritis, as well as answers to CQs, recommendations, and evidence levels for the treatment of vestibular neuritis. CONCLUSION The diagnostic criteria for vestibular neuritis were based on clinical history and examination findings after completing the differential diagnosis process. The treatment of vestibular neuritis was divided into acute, subacute, and chronic stages. The Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021 should be used as a reference in the diagnosis and treatment of vestibular neuritis.
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Affiliation(s)
- Makoto Hashimoto
- Department of Otolaryngology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Izumi Koizuka
- Department of Otolaryngology, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Hiroshi Yamashita
- Department of Otolaryngology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Mamoru Suzuki
- Department of Otolaryngology, Tokyo Medical University, Tokyo, Japan
| | - Koichi Omori
- Department of Otolaryngology-Head and Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideki Origasa
- Department of Biostatistics and Clinical Epidemiology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Noriaki Takeda
- Department of Otolaryngology, University of Tokushima School of Medicine, Tokushima, Japan
| | - Hideo Shojaku
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
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Hunter BR, Wang AZ, Bucca AW, Musey PI, Strachan CC, Roumpf SK, Propst SL, Croft A, Menard LM, Kirschner JM. Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:846-855. [PMID: 35849408 DOI: 10.1001/jamaneurol.2022.1858] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Acute vertigo can be disabling. Antihistamines and benzodiazepines are frequently prescribed as "vestibular suppressants," but their efficacy is unclear. Objective To assess the efficacy of antihistamines and benzodiazepines in the treatment of acute vertigo from any underlying cause. Data Sources We searched the PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and ClinicalTrials.gov databases from inception to January 14, 2019, without language restrictions. Bibliographies of the included studies and relevant reviews were also screened. Study Selection We included randomized clinical trials (RCTs) comparing antihistamine or benzodiazepine use with another comparator, placebo, or no intervention for patients with a duration of acute vertigo for 2 weeks or less. Studies of healthy volunteers, prophylactic treatment, or induced vertigo were excluded, as were studies that compared 2 medications from the same class. Data Extraction and Synthesis Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, data were extracted and risk of bias was assessed by 2 authors independently for each study. Data were pooled using a random-effects model. Main Outcomes and Measures The predefined primary outcome was change in 10- or 100-point vertigo or dizziness visual analog scale (VAS) scores at 2 hours after treatment. Secondary outcomes included change in nausea VAS scores at 2 hours, use of rescue medication at 2 hours, and improvement or resolution of vertigo at 1 week or 1 month. Results Of the 27 trials identified in the systematic review, 17 contributed to the quantitative meta-analysis and involved a total of 1586 participants. Seven trials with a total of 802 participants evaluated the primary outcome of interest: single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1 [95% CI, 7.2 to 25.0]) but not compared with other active comparators (difference, 2.7 [95% CI, -6.1 to 11.5]). At 1 week and 1 month, neither daily benzodiazepines nor antihistamines were reported to be superior to placebo. RCTs comparing the immediate effects of medications (at 2 hours) after a single dose generally had a low risk of bias, but those evaluating 1-week and 1-month outcomes had a high risk of bias. Conclusions and Relevance Moderately strong evidence suggests that single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines. Furthermore, the available evidence did not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo. Other evidence suggested that daily antihistamine use may not benefit patients with acute vertigo. Larger randomized trials comparing both antihistamines and benzodiazepines with placebo could better clarify the relative efficacy of these medications.
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Affiliation(s)
- Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Alfred Z Wang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Antonino W Bucca
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis.,Department of Emergency Medicine, Parma Medical Center, University Hospitals, Parma, Ohio
| | - Paul I Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Steven K Roumpf
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Steven L Propst
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis.,Department of Emergency Medicine, University of Missouri, Springfield
| | - Alexander Croft
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Laura M Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Jonathan M Kirschner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
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Emergency medicine updates: Droperidol. Am J Emerg Med 2022; 53:180-184. [DOI: 10.1016/j.ajem.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/31/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022] Open
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Prospective real-time evaluation of the QTc interval variation after low-dose droperidol among emergency department patients. Am J Emerg Med 2022; 52:212-219. [PMID: 34959024 PMCID: PMC8761164 DOI: 10.1016/j.ajem.2021.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To assess the QTc interval variation after low-dose droperidol in a population of undifferentiated, stable, and non-agitated patients receiving droperidol in the emergency department. METHODS Prospective cohort study of patients aged ≥12 years of age who received low-dose droperidol (≤ 2.5 mg) for indications other than acute behavioral disturbances. QTc intervals were monitored in real-time during pre-specified observation periods in the ED. Primary outcome was variation of QTc interval after droperidol administration, defined as the maximum delta (change) of QTc interval. Other outcomes included proportion of patients with a QTc ≥ 500 ms after droperidol, delta ≥ +60 ms, and incidence of clinical adverse events. Patients were monitored up to 30 min after IV bolus and up to 46 min after infusion. RESULTS A total of 68 patients were included (mean age 42.1 years, 66.2% females). The median dose of droperidol was 1.875 mg (range 0.625 mg, 2.5 mg) and 94.1% received droperidol for headache management. Most patients received droperidol as a 2-min bolus (n = 41, 60.3%). The mean maximum delta of QTc interval after droperidol across all 68 patients was +29.9 ms (SD 15). A total of 12 patients (17.6%) experienced a QTc interval ≥ 500 ms during the observation period after droperidol, and 3 patients (4.4%) had a delta QTc ≥ +60 ms. There were no serious arrhythmias, such as TdP, or deaths among the 68 participants in this study (0/68). However, 13.2% (n = 9) had at least one non-serious adverse event including restlessness and/or anxiety. CONCLUSION The QTc interval slightly increased after droperidol administration, but these prolongations were brief, mostly below 500 msec and did not lead to serious arrhythmias. The yield of continuous cardiac monitoring in patients receiving low doses of droperidol is likely low.
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Abstract
Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.
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Affiliation(s)
- Mallory J Raymond
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue MSC 550, 11th Floor, Charleston, SC 29425, USA
| | - Esther X Vivas
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, 550 Peachtree Street Northeast, 11th Floor, Atlanta, GA 30308, USA.
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Ercin D, Erdur B, Turkcuer I, Seyit M, Ozen M, Yilmaz A, Zincir Ercin DO. Comparison of efficacy dimenhydrinate and metoclopramide in the treatment of nausea due to vertigo; a randomized study. Am J Emerg Med 2020; 40:77-82. [PMID: 33360021 DOI: 10.1016/j.ajem.2020.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study aimed to compare the therapeutic efficacy of dimenhydrinate and metoclopramide in patients with nausea and vertigo. METHODS A prospective, double-blind, randomized clinical trial was performed on patients who presented to the emergency department (ED) with nausea and vertigo in the six month period between Nov 1st 2012 and May 1st 2013. Adult patients who were 18 to 65 years old presenting to the ED with nausea and vertigo or motion sickness were included in the study. A total of 200 patients were divided into 2 groups who were admitted to ED with complaints of vertigo accompanied by nausea. In the first group, 50 mg dimenhydrinate and 10 mg metoclopramide infusions were given intravenously for 15 min. The efficacy of treatment was measured by using a 10 mm Visual Analog Scale (VAS) performed at 0, 15 and the 30th minute. The primary outcome variable was a reduction in vertigo intensity documented on the VAS at the 30th minute after medication administration. RESULTS A total of 200 patients were included in the randomization (n=100 in both groups). The baseline vertigo VAS scores were 7.57±1.42 in the dimenhydrinate (DMT) group and 7.27±1.40 in the metoclopramide (MTP) group (p=0.09). In the 30th minute of treatment, the average vertigo VAS score was 2.46 ± 2.39 in the DMT group and 2.31±1.96 in the MTP group; no significant differences were detected between groups. The baseline nausea VAS scores were 7.62±1.48 in the DMT group and 7.45±1.27 in the MTP group (p=0.36). In the 30th minute of treatment the average vertigo VAS score decreased to 2.27±2.24 in the DMT group and 2.70±2.48 in the MTP group, no significant differences were detected between groups. No significant differences were detected between nausea VAS changes and vertigo VAS changes at 30th minutes of the treatment (p=0.06, p=0.85 respectively). Rescue medication need was similar in both treatment groups (p=0.94). No significant differences were detected about the side effects which are sedation (p=0.56) and hypotension (p=0.57). CONCLUSIONS In conclusion, this prospective, double-blind, randomized study showed that both DMT and MTP have similar efficacy in reducing nausea and vertigo symptoms in the ED.
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Affiliation(s)
- Dogan Ercin
- Kafkas University Faculty of Medicine, Department of Emergency Medicine, Kars, Turkey.
| | - Bulent Erdur
- Pamukkale University Faculty of Medicine, Department of Emergency Medicine, Denizli, Turkey
| | - Ibrahim Turkcuer
- Pamukkale University Faculty of Medicine, Department of Emergency Medicine, Denizli, Turkey
| | - Murat Seyit
- Pamukkale University Faculty of Medicine, Department of Emergency Medicine, Denizli, Turkey
| | - Mert Ozen
- Pamukkale University Faculty of Medicine, Department of Emergency Medicine, Denizli, Turkey
| | - Atakan Yilmaz
- Pamukkale University Faculty of Medicine, Department of Emergency Medicine, Denizli, Turkey
| | - Dilek Ozge Zincir Ercin
- Kafkas University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Kars, Turkey
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Majdi A, Naseri Alavi SA. Comment on "Is cinnarizine/betahistine combination superior to respective monotherapies in treatment of vertigo? A randomized triple-blind placebo-controlled trial". Eur J Clin Pharmacol 2020; 76:609-610. [PMID: 31932872 DOI: 10.1007/s00228-020-02834-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Alireza Majdi
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Cinnarizine/betahistine combination vs. the respective monotherapies in acute peripheral vertigo: a randomized triple-blind placebo-controlled trial. Eur J Clin Pharmacol 2019; 75:1513-1519. [DOI: 10.1007/s00228-019-02741-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/09/2019] [Indexed: 11/26/2022]
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Antiemetic Use in the Emergency Department. Adv Emerg Nurs J 2017; 39:97-105. [PMID: 28463865 DOI: 10.1097/tme.0000000000000141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nausea and vomiting are 2 of the most common complaints of patients presenting to the emergency department (ED). In addition, antiemetics are the most commonly prescribed medications in the ED behind analgesics. Treating these conditions can be complex, especially as one considers that nausea and/or vomiting could be the primary presenting illness or simply a symptom of a more complex etiology. Although there is a wide variety of pharmacotherapeutic options in the armamentarium to treat these conditions, very few consensus recommendations exist to help guide the use of antiemetic agents in the ED, leading to wide variability in medication use. Contributing to these variations in practice is the extended spectrum of etiologies and potential physiological factors that contribute to the development of nausea or vomiting. A thorough understanding of the pharmacology and administration of these agents can help practitioners devise tailored antiemetic regimens based upon the underlying etiology.
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Greco A, Macri GF, Gallo A, Fusconi M, De Virgilio A, Pagliuca G, Marinelli C, de Vincentiis M. Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo? J Immunol Res 2014; 2014:459048. [PMID: 24741601 PMCID: PMC3987789 DOI: 10.1155/2014/459048] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 12/23/2013] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To review the current knowledge of the aetiology of vestibular neuritis including viral infections, vascular occlusion, and immunomediated mechanisms and to discuss the pathogenesis with relevance to pharmacotherapy. SYSTEMATIC REVIEW METHODOLOGY Relevant publications on the aetiology and treatment of vestibular neuritis from 1909 to 2013 were analysed. RESULTS AND CONCLUSIONS Vestibular neuritis is the second most common cause of peripheral vestibular vertigo and is due to a sudden unilateral loss of vestibular function. Vestibular neuronitis is a disorder thought to represent the vestibular-nerve equivalent of sudden sensorineural hearing loss. Histopathological studies of patients who died from unrelated clinical problems have demonstrated degeneration of the superior vestibular nerve. The characteristic signs and symptoms include sudden and prolonged vertigo, the absence of auditory symptoms, and the absence of other neurological symptoms. The aetiology and pathogenesis of the condition remain unknown. Proposed theories of causation include viral infections, vascular occlusion, and immunomediated mechanisms. The management of vestibular neuritis involves symptomatic treatment with antivertiginous drugs, causal treatment with corticosteroids, and physical therapy. Antiviral agents did not improve the outcomes.
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Affiliation(s)
- A. Greco
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - G. F. Macri
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - A. Gallo
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - M. Fusconi
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - A. De Virgilio
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - G. Pagliuca
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - C. Marinelli
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
| | - M. de Vincentiis
- Organs of Sense Department, ENT Section, Policlinico “Umberto I” University of Rome “Sapienza”, Lgo Valerio Bacigalupo 32 C, 00142 Rome, Italy
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