It’s not dead yet!

Reading over a recent article published in the Journal of Emergency Medicine that compares the effectiveness of meclizine versus diazepam for treating vertigo (including BPPV), I was reminded of that cliché scene in so many horror movies. The bad guy is finally dead. He has an axe in his chest, or something equally unsurvivable (is that a word?). The potential victims are hugging and celebrating their victory, not paying any attention to the bad guy with the axe in his chest and BOOM! The bad guy gets up, takes the axe out of his chest and starts swinging at the knuckleheaded couple that probably should have hightailed it out of there when they had the chance.

I sometime feel this way about meclizine, because, despite a lot of recent information recommending against the use of meclizine for most types of “dizziness,” it is still being used on a too frequent basis. If you Google “BPPV meclizine”, you will find a number of posts telling you this is not the best treatment. If you read the AAO-HNS Clinical Practice Guideline for BPPV, you will find this :

STATEMENT 6. MEDICAL THERAPY: Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines.Recommendation against routine medication based on observational studies and a preponderance of benefit over harm.

This is not new information as the initial BPPV guideline published in 2008 says essentially the same thing. Yet, this recent article describes meclizine as a treatment option for BPPV. While the article does recognize that canalith repositioning is the best option for the treatment of BPPV, the authors state that:

“When a diagnosis of BPPV has been made in the outpatient setting, many experts advocate for the first-line therapy of a canalith repositioning procedure (CRM) . However, the ED literature is less clear on this issue. The preponderance of CRM studies of effectiveness for BPPV were completed in outpatient non-ED settings. An emergency medicine evidence-based medicine analysis identified ED setting studies. However, questions were raised regarding the effectiveness of CRM for BPPV in the ED setting”

I downloaded and read the two articles referenced for the statement about “questions were raised regarding the effectiveness of CRM for BPPV in the ED setting.” Here is the gist of those two articles:

A 2000 review article in the Annals of Emergency Medicine states “Routine use of vestibular suppressants (meclizine and benzodiazepines) as primary therapy is discouraged because they do not reduce the frequency of attacks of vertigo. They may diminish the intensity of the attacks and prevent the patient from seeking treatment from a potentially curable disease, and they often worsen the patients imbalance. Short term use on an as-needed basis in patients with severe symptoms may be appropriate provided adequate follow up with an otolaryngologist or neurologist is obtained.” So, even before the 2008 BPPV Clinical Practice Guideline came out, there was some recognition of the problems associated with treating BPPV with meclizine or diazepam.

 The second reference article is more recent, published in The Journal of Emergency Medicine in 2014. This article recognizes that “It is common practice for ED physicians to treat these (BPPV) patients symptomatically with benzodiazepines, antihistamines, or anticholinergic medications.” This study compared levels of nausea, dizziness and patient satisfaction in two groups of patients diagnosed with BPPV. Some were treated with Canalith Repositiong Procedures (CRP), while others were treated with vestibular suppressant medication. They found no significant differences between the two groups. Despite this, the author’s summary expresses concern about the lack of CRP offered in the ED (less than 4%), and state “what barriers exist to prevent it’s regular use is difficult to explain.” They go on the conclude “Considering the cost savings, nursing time, and potential for adverse reactions to medications (even the limits on driving due to sedation) and complications from IV access, it seems the maneuvers has clear advantages for those so motivated to attempt it.”

 This brings us back to the original article comparing meclizine to diazepam in treating vertigo, keeping in mind that not all vertigo is caused by BPPV. If we can all agree that medications is not the best treatment for BPPV, then the findings of this study are interesting and useful. The authors found that meclizine and diazepam were equally effective in reducing dizziness and nausea at 60 minutes, and that there was no difference in patient satisfaction level between the two groups. I had been under the impression for many years that diazepam had a distinct advantage over meclizine in the treatment of acute vertigo. To be honest, I am not sure where I got that impression. There is one excerpt in this article that helps explain the differences in approach between ED physicians and ENT/Audiology types. “ED assessment focuses on ruling out serious causes of vertigo and rapid symptomatic improvement. Improvement in patient symptoms allows for ED discharge and referral for follow up and definitive diagnosis and treatment.”

 For more information regarding the use of meclizine, click here

 

 

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