The pharmacological management of vertigo in Meniere disease

ABSTRACT

Introduction

The term Meniere disease (MD) gathers a set of rare diseases involving the inner ear characterized by episodic vertigo associated with fluctuating auditory symptoms. Five clinical subgroups of patients have been defined, including familial MD, autoimmune MD, and MD with migraine. The diagnosis is based on clinical criteria as no biomarker is available, but genetic factors have a significant contribution in familial and non-familial MD.

Areas covered

In this review, the authors summarize the pharmacological treatment for vertigo in MD, providing evidence from preclinical and clinical studies. However, evidence supporting the efficacy for betahistine, diuretics, and intratympanic administration of corticosteroids or gentamicin is limited.

Expert opinion

Randomized clinical trials should consider stratification by MD clinical subgroups. The treatment plan should be personalized according to the clinical subgroup, hearing stage, duration of the disease, vertigo attack profile, and comorbidities. The treatment should include therapeutic counseling, sodium-free diet, high-water intake, and a diary of vertigo attacks with symptoms during the episodes to improve phenotyping. Migraine or autoimmune comorbidities will also require pharmacotherapy. Genetic testing by exome/genome sequencing should be discussed with the patient for familial MD and individuals with an early onset for genetic counseling and future gene therapies.

KEYWORDS:

• Betahistine
• corticosteroids
• diuretics
• gentamicin
• Meniere´s disease
• treatment
• genetics
• vertigo
• hearing loss
• tinnitus

Article highlights

• MD is a set of rare inner ear disorders characterized by recurrent episodes of spontaneous vertigo, associated with fluctuating auditory symptoms.

• MD pharmacotherapy should be personalized, according to clinical subgroup, stage of the disease, years from onset, number and profile of vertigo attacks, degree of hearing loss, and other comorbid conditions.

• Vestibular suppressants and antiemetic agents are the preferred drugs for the treatment of the acute phase, whereas the main goal of pharmacological treatment is to reduce the frequency, duration, and severity of vertigo attacks.

• The pharmacological options include betahistine, diuretics, intratympanic administration of corticosteroids, or gentamicin in a stepped approach. Nevertheless, evidence supporting drug therapy is lacking or limited.

• The heterogeneity of the disease makes it necessary to investigate the efficacy of these drugs in different clinical subgroups. Long-term multicenter, randomized, placebo-controlled clinical trials are required in different clinical subgroups of MD.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

Jose Antonio Lopez Escamez [JALE] was partially funded by grants INT18/00031 and PI17/1644 from the Instituto de Salud Carlos III (ISCIII) from European Regional Development Funds.