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Diagnosis and Management of
Vertigo
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Todays Talk
Dizziness and Vertigo
Vertigo Diagnosis
Treatment Options Focus of Betahistine in Vertigo Management
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Dizziness
Third most common complaint among all outpatients1
Single most common complaint among patients older than
75 years1
Generic term used to describe a variety of experiencesincluding giddiness, lightheadedness, faintness, vertigo,
fogginess, imbalance, unsteadiness and ataxia2
1. Chawla N, Olshaker J. Med Clin N Am 2006; 90: 291-304
2. Nettina S. Topics in Adv Nurs, [ejournal] assessed online Oct 09
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Dizziness
Dizziness refers to various abnormal sensations relating
to perception of the bodys relationship to space1
Dizziness can be caused by many different medical
conditions2
It is estimated that as many as half of cases are due to
vestibular disorders2
1. Sloane P et al, Ann Intern Med 2001; 134: 823-32
2. Hall C and Cox C. Otolaryngol Clin N Am 2009: 42: 161169
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Types of Dizziness
Vertigo
Presyncopal lightheadedness
Disequilibrium
Other dizziness
Sloane P et al, Ann Intern Med 2001; 134: 823-32
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Vertigo
It is a false sensation that the body or the environment is
moving (usually spinning) and suggests a disturbance of
the vestibular system1
Accounts for 54% of cases of dizziness2
Vestibular vertigo affects more than 5% of adults in 1 year
in the Unites States3
Incidence increases with age4
1. Sloane P et al, Ann Intern Med 2001; 134: 823-32
2. Lauuguen R. Am Fam Physician 2006; 73: 244-54
3. Neurology 2005;65:898-904
4. Samy H et al. www.emedicine.medscape.com as accessed on October 2009
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Types of Vertigo
Peripheral
Central
Other types
Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304
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Peripheral Vertigo
Arise from abnormalities in the vestibular end
organs (semicircular canals and utricle), the
vestibular nerve, and the vestibular nuclei.
Most of these causes are benign and readily
treatable
Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304
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Peripheral Vertigo
BPPV
Acutesuppurative
labyrinthitis
Vestibular
neuritis
Menieres
Disease
Acoustic
neuroma
TraumaChawla N and Olshaker J.
Med Clin N Am 2006; 90: 261-304BPPV= Benign parosxymal positional vertigo
Types of
Peripheral Vertigo
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Central Vertigo
There is an involvement of the brain especially the
cerebellum
Exhibits more serious consequences and
aggressive treatment is recommended
Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304
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Central Vertigo
Cerebellarhemorrhage
Brainstemischemia
VertebrobasilarInsufficiency
Types of
Central Vertigo
Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304
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Characteristics Peripheral Central
Severity Severe Mild
Onset Sudden Gradual
Duration Seconds to Minutes Weeks to Months
Positional Yes No
Fatigable Yes No
Postural instability Able to walk;
unidirectional instability
Falls while walking;
severe
Hearing loss or tinnitus Can be present Usually absent
Other neurologic
symptoms
Absent Usually present
Associated Nystagmus Horizontal Vertical
Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304. Swartz R. Am Fam Physician 2005; 71: 1129-30
Clues to Distinguish
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Most common causes of Vertigo
Benign Paroxysmal positional vertigo (BPPV)
Menieres disease
Vestibular Neuritis
Brandt T, Zwergal A, Strupp M. Expert Opin Pharmacother 2009; 10: 1537-48
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Todays Talk
Dizziness and Vertigo
Vertigo Diagnosis
Treatment Options Focus of Betahistine in Vertigo Management
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Diagnosis
P ti t l i
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Patient complains
of dizzinessDoes the patient have true vertigo?
Ask: Possible cause Comment
Q. Does the room spin
around?
A. Yes
Vertigo An illusion of movement, often horizontal
and rotatory. Associated nausea and
vomiting indicate a peripheral rather than
central cause.
Q. Do you feel unsteady?
A. Yes
Dysequilibrium May result from peripheral neuropathy,
eye disease, musculoskeletal weaknessor peripheral vestibular disorders.
Q. Do you feel like you may
faint?
A. Yes
Presyncope Caused by cardiovascular disorders
reducing cerebral perfusion
Q. Do you feel lightheaded?
A. Yes
Lightheadedness
is non-specific
and hard to
diagnose
It may result from panic attacks with
hyperventilation
Kanagalingam J et al. BMJ 2005; 330: 523
P ti t l i
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Patient complains
of dizzinessDoes the patient have true vertigo?
Is the patient taking any
Drug that can cause vertigo?
Continue evaluation appropriate for
Lightheadedness, presyncope, or
disequilibrium
YES NO
Aminoglycosides
Furosemide
Ethacrynic acid,Acetylsalicyclic acid,
Amiodarone
Quinine,
Cisplatinum,
Anti-Alzheimersmedications
Anticonvulsants,
Antidepressants,
Anxiolytics.Alcohol
Nicotine
Caffeine
Medications and substances that can cause dizziness or vertigo
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304Labuguen RH. Am Fam Physician 2006; 73: 244-51
P ti t l i
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Patient complains
of dizzinessDoes the patient have true vertigo?
Is the patient taking any
Drug that can cause vertigo?
Continue evaluation appropriate for
Lightheadedness, presyncope, or
disequilibrium
YES NO
YES NO
Consider stopping
medicationIf possible
Obtain general History
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Obtaining History
Ask for family history including hereditary conditions such
as migraine and risk factors for cerebrovascular disease
Sexual history should also be noted. Certain sexually
transmitted diseases such as syphilis have otologicsymptoms
Consider age, as it is associated with some underlying
conditions (diabetes or hypertension) and these conditions
are associated with higher risk of cerebrovascular causes
of vertigo
Labuguen RH. Am Fam Physician 2006; 73: 244-51
Kanagalingam J et al. BMJ 2005; 330: 523
Patient complains
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Patient complains
of dizzinessDoes the patient have true vertigo?
Is the patient taking any
Drug that can cause vertigo?
Continue evaluation appropriate for
Lightheadedness, presyncope, ordisequilibrium
YES NO
Consider stopping
medicationIf possible
Obtain general HistoryNo history of other possible causes
of vertigo
Obtain history on the duration of vertigo
YES NO
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Features Possible Diagnosis
Spontaneous episodes (i.e. no
consistent provoking factors)
Unilateral loss of vestibular function
Spontaneous episodes (i.e. noconsistent provoking factors)
Nausea and/or vomiting
Late stages of Menieresdisease
Moderate imbalance
Nausea and vomiting
Late stages of acute vestibular neuronitis
Vertigo lasting for few seconds
Goebel J. Otolayngol Clin N Am 2000; 33:483-93
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304
Labuguen RH. Am Fam Physician 2006; 73: 244-51
Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Vertigo lasting for several seconds to
few minutes
Features Possible Diagnosis
Induced by position change
History of cervical spine trauma
Nausea and/or vomiting
Benign paroxysmal positional vertigo
Induced by changes in head
position
Changes in ear pressure, head
trauma, excessive straining, loud
noises Hearing loss
Perilymphatic fistula* or
Superior semicircular canal dehiscence
* vertigo with perilymphatic fistula can also last from several minutes to hours
Goebel J. Otolayngol Clin N Am 2000; 33:483-93 Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304Labuguen RH. Am Fam Physician 2006; 73: 244-51 Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Vertigo lasting for several minutes to
hours
Features Possible Diagnosis
Cardiovascular risk factors
Neurological symptoms
Hearing loss (In case of involvement
of the inferior cerebellar artery
involvement)
Transient ischemic attack or stroke
Goebel J. Otolayngol Clin N Am 2000; 33:483-93
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304
Labuguen RH. Am Fam Physician 2006; 73: 244-51
Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Vertigo lasting for hours
Features Possible Diagnosis
Fluctuating hearing loss
Tinnitus, aural fullness
Menieresdisease
History of migraine Headache#
Visual aura#
Phonophobia, photophobia
Migrainous vertigo
# Typical headache and aura is absent
Goebel J. Otolayngol Clin N Am 2000; 33:483-93
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304
Labuguen RH. Am Fam Physician 2006; 73: 244-51
Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Vertigo lasting for days
Features Possible Diagnosis
Severe nausea and vomiting
Recent upper respiratory viral
illness or middle ear illness
Moderate imbalance
Nausea and vomiting
Early acute vestibular neuritis
Labyrinthits (if hearing loss is present)
Imbalance
Focal neurological findings
Cerebellopontine angle tumour;
cerebrovascular disease; multiple sclerosis
Goebel J. Otolayngol Clin N Am 2000; 33:483-93
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304
Labuguen RH. Am Fam Physician 2006; 73: 244-51
Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Vertigo lasting for weeks
Features Possible Diagnosis
History of anxiety, panic disorder or
depression
Psychogenic vertigo
Goebel J. Otolayngol Clin N Am 2000; 33:483-93
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304
Labuguen RH. Am Fam Physician 2006; 73: 244-51
Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
Patient complains D th ti t h t ti ?
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Patient complains
of dizzinessDoes the patient have true vertigo?
Is the patient taking any
Drug that can cause vertigo?
Continue evaluation appropriate for
Lightheadedness, presyncope, ordisequilibrium
YES NO
Consider stopping
medicationIf possible
Obtain general HistoryNo history of other possible causes
of vertigo
Obtain history on the duration of vertigo
YES NO
Perform head and neck
and cardiovascular examination
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Head and Neck Examination
Findings Inference
Vesicles on the tympanic membrane Herpes zoster oticus
Henneberts sign (i.e., vertigo or nystagmus
caused by pushing on the tragus and external
auditory meatus of the affected side)
Perilymphatic fistula
Valsalva maneuver (i.e., forced exhalation with
nose plugged and mouth closed to increase
pressure against the eustachian tube and inner
ear) causes vertigo
Perilymphatic fistula or Superior
semicircular canal dehiscence
Other otoscopic findings Cerumen impaction or any foreign
object in the ear canal
Fluid behind the ear drum, perforation or extensive
scarring
Middle ear disease (ototis media,
chronic otitis, cholesteatoma etc)
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304 Labuguen RH. Am Fam Physician 2006; 73: 244-51Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Cardiovascular Examination
Findings Inference
Orthostatic changes in systolic blood pressure
(e.g., a drop of 20 mm Hg or more) and pulse (e.g.,
increase of 10 beats per minute) upon standing
Orthostatic hypotension, dehydration
etc
Carotid bruit, heart murmur or irregular rhythm Cardiac arrhythmia
Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304 Labuguen RH. Am Fam Physician 2006; 73: 244-51Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
Patient complains Does the patient have true vertigo?
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Patient complains
of dizzinessDoes the patient have true vertigo?
Is the patient taking any
Drug that can cause vertigo?
Continue evaluation appropriate for
Lightheadedness, presyncope, ordisequilibrium
YES NO
Consider stopping
medicationIf possible
Obtain general HistoryNo history of other possible causes
of vertigo
Obtain history on the duration of vertigo
YES NO
Perform head and neck
and cardiovascular examination
Perform
neurologic examination
Negative
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Neurological Examination
Fixation suppression test
Head Thrust Test (Head Impulse Test)
Posthead shake nystagmus Dix-Hallpike Maneuver
Positional Tests
Goebel J. Semin Neurol 2001: 21: 391-8
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Warning clinical features warranting
neuroimaging
Very sudden onset (seconds) of vertigo that persists and
not provoked by position
Association with new onset of (occipital) headache
Association with deafness but no typical Meniereshistory
Acute vertigo with normal head impulse test
Associated with central neurological signs such as severe
gait and truncal ataxia
Hung Kuo C. Aus Fam Physician 2008; 37: 341-47
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Todays Talk
Dizziness and Vertigo
Vertigo Diagnosis
Treatment Options Focus of Betahistine in Vertigo Management
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Treatment
Vestibular Rehabilitation Therapy (VRT)
Pharmacotherapy
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Vestibular Rehabilitation Therapy
Involves series of maneuvers involving head, eye and body
movements
These stimulate the in-build adaptive mechanism
Helps patients with peripheral vestibular hypofunction toreturn to normal activities of daily living and a high quality of
life
Kirtane M. Ind J Otolaryngol HNS 1999; 51: 27-36
Hall C, Cox C. Otolaryngol Clin N Am 2009;42: 161169
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VRT- Goals
Improve balance
Minimize falls
Decrease subjective sensations of dizziness
Improve stability during locomotion Reduce overdependency on visual and somatosensory
inputs
Improve neuromuscular coordination Decrease anxiety and somatization due to vestibular
disorientation
Zapanta P . http://emedicine.medscape.com/article/883878-print as accessed on December 2009
EXERCISES IN BED EYE AND HEAD MOVEMENTS
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EXERCISES IN BED : EYE AND HEAD MOVEMENTS
Looking up and down
Looking alternately left and right
Convergence Exercises
Bending alternately
forward and backward
Turning alternatively tothe left and then ri ht
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EXERCISES IN STANDING POSITION
Changing from sitting
to standing, initially
with eyes open and
then with the eyes closed
Throwing a small (ping
pong) ball in, an
arc from hand to
hand and following
it with the eyes
Throwing a small ballfrom hand to hand
under the knee
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EXERCISES WHILE WALKING
Throwing and catching
the ball while walking
Playing any game involving bending,stretching and aiming with the ballWalking up and down a flight of stairs
Walking around in the room
with eyes open and closed
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EXERCISES IN SITTING POSITION
Shrugging and
rotating shoulders
Bending forward and
picking up objects from the
floor
Turning head and trunk
alternately to the left and the right
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Aims of Symptomatic treatment
Eliminate vertigo
Enhance or at least non compromise- of the process of
vestibular compensation
Reduction of neuro-vegetative and pyschoaffective signs-nausea, vomiting, anxiety, that often accompany vertigo
Rascol O et al, Drugs 1995; 50: 777-91
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Vestibular compensation (VC)
VC is a natural process bywhich the brain helps thebody overcome the feelingof vertigo
Takes place mainly atvestibular nuclei (astructure present in thebrain stem)
The vestibular nucleireceives inputs from thetwo ears from each side
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Vestibular Deficit in Vertigo
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Vestibular Deficit in Vertigo
Vestibular
Nuclei
INTACT DAMAGED
Imbalance of activity at vestibular
nuclei causes vertigo
Lacour M. Curr Med Res Opion 2006; 22: 1651
Vestibular
Nuclei
INTACT INTACT
Normal individual
NOSE
EAR
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Reasons for reduced activity at VN of the
damaged side
Vestibular
Nuclei
INTACT DAMAGED
Imbalance of activity at vestibularnuclei causes vertigo
(1) Reduced input
from the ear(2) Inhibition by
the intact VN
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Vestibular Compensation
There is an increase inhistamine levels at VN by thebrain
Histamine helps achieve VC
However, it takes about 3months for by our body toachieve VC and overcomethe symptom of vertigo
Hence, treatment should befocused towards hasteningVC
Vestibular
Nuclei
INTACT DAMAGED
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Lacour M. J Clin Pharmacol (In press)
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Classification of Pharmacotherapy for
management of Vertigo
Vestibular Suppressants
Drugs that facilitate compensation process
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Treatment with Vestibular Suppressants
Suppressants reduceactivity at intact side andthus hamper recovery byVC
Hence, they are notrecommended for longterm use
They should bediscontinued as soon aspossible
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
VestibularNuclei
INTACT DAMAGED
C l d tib l
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Commonly used vestibular
suppressants in practice
Drug Dosage Adverse Reactions
Meclizine 12.5-50 mg TID Sedating, precaution in
prostatic enlargement
Cinnarizine 30 mg TID Sedation, CNS
depression
Prochlorperazine 5 to 10 mg BID or TID Extrapyramidal side
effects
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Vestibular Suppressants
Useful for prevention of nausea and reduce vomiting
(generally to be used for not more that 1-3 days) post an
event
Should be discontinued as soon as possible after eventsubsides
They are not to be used chronically or for prophylaxis
against subsequent attacks
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Goebel J. Otolaryngol Clin N Am 2000; 33: 483-93
Brandt T, Vertigo. Its Multisensory Syndromes, 2ndEd: Pg 49-61
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Todays Talk
Dizziness and Vertigo
Vertigo Diagnosis
Treatment Options
Focus of Betahistine in Vertigo Management
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Eff t f b t hi ti
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Effect of betahistine
on locomotor balance recovery in cats
Betahistine treated cats showed a time benefit of
2 weeks in maximum performance
This time benefit was due to early
achievement of compensation
Tighilet B, Leonard J, Lacour M. J Vest Res 1995;5:53-66
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Role of betahistine in VC
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Vestibular
Nuclei
INTACT DAMAGED
Lacour M. Curr Med Res Opion 2006; 22: 1651-9; Lacour M. J Clin Pharmacol (In press)
(2) Increases the activity
of the damaged VN by H1
agonistic action
(3) Reducing inhibition byintact by H3 hetro
antagonistic
action
(1) Increasing the levels
of histamine in the VN by
H3 auto antagonistic action
Betahistine helps achieve the activity of the damaged side within 1 month
Giving a time benefit of 2 months !! As compared to the natural course of VC
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Clinical Studies
Superior to placebo in reducing frequency of
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Superior to placebo in reducing frequency of
vertigo
18 ENT practicesin the Netherlands
82 patients
suffering from
vertigo of
various origins
Oosterweld et al, JDR
J Drug TherRes1989; 14:122-6
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Effective in both Menieresand BPPV
Mira et al,
Eur Arch Otorhinolaryngol 2003; 260: 73-7
144 patients suffering from recurrent vertigo
related to Menieres disease or PPV
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Effective in acute vertigo
N=29 outpatients with acute vertigo Bradoo et al, Indian JOHNS 2000; 52: 151-8
Week 0 Week 1 Week 2 Week 3
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Comparable Efficacy:
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24 mg BID vs. 16 mg TID
N= 120 ptns with well established Meniers Disease Gananca M et al,
Acta Oto-Laryngologia 2008; 1-6
24 mg BID is as effective as 16 TID in terms
of reduction in vertigo spells
There was no difference between groups in terms ofincidence of adverse events
24 mg BID would be of particular importance in
patients non-adherent or partially adherent to treatment
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High Dose, Long Duration Studies
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Effect on cerebral blood flow
SPECT- Indian Study
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MRISPECT
R L R L
Reference Image
Pre-Betahistine Therapy (15.06.1999) No. 2540
Post-Betahistine Therapy (12.07.1999) No.2922
(A)
SPECT Indian Study
Krisha BA, Kirtane MV et al
Neurology India 2000; 48: 255-9
11 patients with no peripheral vertigo
and with probable diagnosis
of ischemia (lack of blood supply) of the
Vertebro-basilar artery were included
Left temporal lobe
SPECT- Indian Study
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MRISPECT
R L R L
Reference Image
Pre-Betahistine Therapy (27.02.1998)
No.791
Post-Betahistine Therapy (10.03.1998) No.1950
(B)
SPECT- Indian Study
11 patients with no peripheral vertigo
and with probable diagnosis
of ischemia (lack of blood supply) of the
Vertebro-basilar artery were included
Right inferior cerebellar region
Krisha BA, Kirtane MV et al
Neurology India 2000; 48: 255-9
SPECT- Indian Study
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Reference Image
SPECT MRI
R L R L
Pre-Betahistine Therapy (17.03.1999)
No.1086
Post-Betahistine Therapy (08.04.1999)No.1599
(C)SPECT Indian Study
11 patients with no peripheral vertigo
and with probable diagnosis
of ischemia (lack of blood supply) of the
Vertebro-basilar artery were included
Right parieto-occipital region
Krisha BA, Kirtane MV et al
Neurology India 2000; 48: 255-9
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Betahistine Versus Other Agents
S i t Ci i i
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Superior to Cinnarizine
Deering RB et,
Curr med Opion 1986; 10: 209-14
88 patients with peripheral vertigo
B t hi ti i t d i d t
-
8/12/2019 New Vertin CME Slides Final
90/98
Betahistine associated superior responder rate
88.7 91.6
7582.4
70.5
79.4
65.8
86.2
63.4
81.5
28.9
51.6
0
10
20
3040
50
60
70
80
90100
Meniere's Disease Other vestibular disorders
P
atient(%)
Betahistine Cinnarizine Clonazepam
Flunarizine Gingko Biloba extract No medication
N=1,100 outpatients with established Mniresdisease or other peripheral vestibulopathies
Gananca et al, Rev Bras Otorrinolaringol 2007;73(1):12-8.
Betahistine associated low incidence of adverse
-
8/12/2019 New Vertin CME Slides Final
91/98
effects compared to others
0
2.1 3
23.8
7.4
2.3
26.2
9.1
0
29.9
13.4
2.3
0
2.84.5
0
17.114.7
0
5
10
1520
25
30
35
Sleepiness Depression Axiety
Patient
(%)
Betahistine Cinnarizine Clonazepam
Flunarizine Gingko Biloba extract No medication
Gananca et al, Rev Bras Otorrinolaringol 2007;73(1):12-8.
N=1,100 outpatients with established Mnires disease or other peripheral vestibulopathies
Superior to Flunarizine
-
8/12/2019 New Vertin CME Slides Final
92/98
Superior to Flunarizine
3.8
0.6
3.9
2
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Day 0 Day 60
Meanseverityofvertigo
Betahistine Flunarizine
Fraysse B et al,
Acta- Otolaryngologica 1991;
Suppl 490: 3-10
55 patients with recurrent vertigo
Superior to prochlorperazine
-
8/12/2019 New Vertin CME Slides Final
93/98
Superior to prochlorperazine
Aantaa E et al; Ann Clin 1976; 8: 284-7
N=30 patients with Menieresdisease
-
8/12/2019 New Vertin CME Slides Final
94/98
-
8/12/2019 New Vertin CME Slides Final
95/98
Jeck-Thole et al, Drug Saf 2006; 29: 1049-59
D
-
8/12/2019 New Vertin CME Slides Final
96/98
Dosage
VERTIN, Prescribing Information
-
8/12/2019 New Vertin CME Slides Final
97/98
-
8/12/2019 New Vertin CME Slides Final
98/98