Vertigo Pharmacotherapy
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1 Vertigo Pharmacotherapy Fatthi Abdel Baki MD Alexandia Medical School Neurotransmitters Pre synaptic neuron Neurotransmitters Post synaptic receptor Post synaptic neuron
2 Main Neurotransmitters Excitatory or Inhibitory Glutamate: Excitatory GABA (2): Inhibitory Other Neurotransmitters Excitatory or Inhibitory Depends on type of receptors: Acetyl choline Nicotinic & Muscarinic (5) Dopamine (5) D1 to D5 Histamine (3) H1; H2;H3 Serotonin 5 HT (7) Nitric oxide
3 Vestibular Lesion Vestibular suppressants Vestibular Stimulants Vertigo Management Plan Acute Episode Speed recovery Target treatment Vertigo Vomiting Nystagmus Vasodilators Rheology Oxygenation Vestibular activity Meniere Vestibular neuritis VBI Migraine Vascular loop
4 Vestibular suppressants Glutamate Calcium ion Histamine Calcium channel blocker Cinnarazine Vestibular activity Antihistamine: Meclizine GABA (B) agonist: Baclofen GABA (A) agonist: Benzodiazepines GABA CTZ Dopamine antagonist (D2) Metoclopramide (Primperan) Antiemetics Dopaminergic pathway Vomiting Centre histaminergic pathway Vestibular Nuclei antihistamines (H1) Meclizine Serotonin blockers (5HT3) Ondansetron (Zofran) GIT Serotenergic pathway
5 Inner ear vessel Speed Recovery Rheology RBC Vaso dilators Histamine agonists Calcium blockers Pentoxyphylline Oxybral Ginko Poor tissue Perfusion & oxygenation Vaso active Buflomedil Calcium blockers Pentoxyphylline Oxygenator Vestibular stimulants Histamine agonists Piribidil Piracetam Ginko Poor vestibular activity almitrine + raubasine Buflomedil Vincamine vinpoctine Drugs: mechanism of Action vestibular Suppressant Anti emetic Vaso Dilator Vaso active O 2 vestibular Stimulant Antihistamine + + Benzodiazepam + Cinnarazine Betahistine + + Vicamine + + almitrine + raubasine + Buflomidil + + Pirebidil + + Pentoxyphilline + + Ginko + +
6 Drugs: Side effects Side Effects / Precautions Antihistamine Benzodiazepam Betahistine Cinnarizine Vincamine Almitrine + Raubasine Buflomedil Pirebidil Pentoxyphylline Sedation; anticholinergic; extrapyramidal Sedation; habituation Bronchial asthma Sedation Hypotension Drowsiness GIT GIT Flushing/headache Betahistine Betaserc Widely used for the management of vertigo. UK (Meniere s): 94% betahistine; 63% diuretics Not approved by the FDA Randomized controlled trial: controversial No EBM Recent large study (144) showed statistically significant improvement Dose mg three times/day for 2 to 40 w Do not use with antihistamine
7 Beta-Histine Action Pre synaptic Histaminergic Nerve ending H3 H H BH H Post-synaptic Microcirculation of inner ear and brain Central activity vestibular nuclei Vestibular compensation Buflomedil HCl Loftyl RBC s deformability RBC s aggregation Platelet aggregation Leukocytic adherence to vessel wall Tissue Oxygenation Tissue Perfusion
8 Alimintrine bismesylate / rabusine Duxil Increases Oxygen availability Increases Oxygen utilization Vincamime Oxybral Increase cerebral flow Increase oxygen capture and utilization by the hypoxic neurons.
9 Dopamine agonists Piribedil Compensate deficient Dopaminergic neurotransmission (aging) Reducing the sympathetic vaso-constricting tone. Ginko Reduces the viscosity of the blood Anti-oxidant. Enhance vestibular compensation in animals
10 Vertigo Target treatment Meniere Vestibular neuritis VBI Migraine Meniere Prophylaxis Vasodilators Diuretics and dietary salt restriction in salt sensitive persons Glucocorticoids in salt insensitive persons Chemical labyrinthectomy
11 Meniere Vasodilators Betahistine (an oral histamine analogue) Role of Betahistine in Meniere disease: No EBM Ions Homeostasis Vasopressin Aldosterone
12 Ions Homeostasis Meniere Increase Vasopressin Aldosterone Diuretic Steroids Meniere Diuretics Potassium loosing diuretics (Thiazide) Multiple undesirable side effects Potassium sparing diuretic (Spironolactone) Homeostasis theory Combined (Thiazide+ Amiloride) Role of diuretics in Meniere: No EBM
13 Meniere Intra- tympanic steroids Methyl prednisolone: solumederol Advantage: Higher concentration in endolymph and perilymph after administration Disadvantage: Slow absorption from endolymph into stria. It remain in endolymph longer than dexa by 6hs Painful Meniere Intra- tympanic steroids Dexamethasone: (fortacorten) Advantage: Faster absorption and diffusion from endolymph into stria and surrounding tissue (steroid act intracellular) Disadvantage: Need high concentration; 24mg /ml not available in market Dose: 24mg (compounding) /cc / week (2 treatment) most effective in early stage
14 Meniere Intratympanic gentamycin Protocol Base line caloric before injection to determine degree of vestibular function in the other ear Standard protocol ml of gentamycin 40mg /ml (12-24 mg) Repeated weekly till end points Low dose protocol Single dose protocol Injection of low concentration (10mg/ml) Repeated after 2-4 weeks if vertigo remains Meniere Intratympanic injections End Point Hearing worsened PTA increase > 15db in 3 consecutive freq. SDS fell > 20 % Head shaking Nystagmus Spontaneous paralytic Head shaking Head thrust 4 scheduled treatment Head thrust
15 Meniere Intractable vertigo Protocol Early stage: Mild / fluctuant hearing loss: Intra-tympanic steroids if failed Vestibular neurectomy Advanced stage: Moderate/ severe HL with poor discrimination: Intra- tympanic gentamycin Vestibular neuritis Management Vestibular suppressant (3 days) Steroids Antiviral Vestibular Rehab.
16 VBI Management Treatment of risk factors: Hyperlipidemia; hypertension; diabetes; smoking Drugs Antiplatelet: Aspirin; plavix; persantin Neck care Collars; Physiotherapy Cautions neck movements Migraine Management Trigger factors: avoidance Drugs: Beta blockers: Propanolol Calcium channel blockers: Cinnarazine TCA antidepressant: Amitryptiline (tryptizol) Novel antiepileptic: Topamax
17 Other conditions Motion sickness Orthostatic hypotension Psychogenic Vertigo (hyperventilation) Juvenile vertigo Senile vertigo "presbyastasis" Microvascular compression Bilateral vestibular loss Treatment of undetermined or ill defined cause of vertigo Motion Sickness Management Prevention: Anticholinergic (scopolamine) pure anticholinergics are ineffective if administered after symptoms have already appeared Treatment: Calcium channel blockers: Cinnarizine Antihistamine: Dramamine
18 Orthostatic Hypotension Nonpharmacologic treatment Slow, careful changes in position, especially on arising in the morning Avoidance of hot environments and hot showers or baths Multiple small meals Increased salt ;fluid and caffeine intake Orthostatic Hypotension Pharmacologic treatment Removal of medications that exacerbate hypotension when possible Fludrocortisone (Florinef) Midodrine (ProAmatine) Sympathomimetics Erythropoietin
19 Psychogenic vertigo Management Drugs: Benzodiazepines SSRI (selective serotonin reuptake inhibitors eg cipralex ) less effectiveness but less habituation Breath into a bag in the event of an attack Psychiatric consultation is suggested. BPV of childhood Management Antiepiletics low dose where the frequency of the attacks is more than once a week..
20 Microvascular compression Management Anti-convulsants: Carbamazepine (Tegretol) Gabapentin (Neuronton) Egyptian Society of ORL WEB SITE Please Register
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