Is the treatment plan of Meclizine (Meclizine) 12.5 mg three times a day as needed (TID PRN) and the Epley Maneuver appropriate for a 56-year-old male patient diagnosed with Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

The treatment plan of Meclizine 12.5 mg three times a day as needed (TID PRN) and the Epley Maneuver is not entirely appropriate for a 56-year-old male patient diagnosed with Benign Paroxysmal Positional Vertigo (BPPV), as the use of vestibular suppressant medications like Meclizine is not recommended for routine treatment of BPPV, according to the 2017 clinical practice guideline update 1. The Epley Maneuver, a specific repositioning procedure, is strongly recommended as initial therapy for patients with posterior canal BPPV 1. Meclizine, an antihistamine, may provide symptomatic relief for vertigo, dizziness, and nausea associated with BPPV by suppressing vestibular input to the brain, but its use should be limited to short-term management of severe symptoms, as there is no evidence that it is effective as a definitive treatment for BPPV 1. The patient should be advised that the Epley Maneuver may need to be repeated several times for maximum effectiveness, and that they should avoid sudden head movements, bending over, or lying flat for 24-48 hours after the procedure. Patient education regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up is crucial, as BPPV can have a significant socioeconomic impact and increase the risk of falls, particularly in the elderly 1. Key aspects of patient education include understanding what BPPV is, its diagnosis and treatment options, the risk of recurrence, and the importance of recognizing recurrent symptoms early to allow for timely return for further treatment. Given the potential for recurrence and the risk of falls associated with BPPV, counseling patients and their families about these risks and providing guidance on home safety and activity restrictions is essential, especially for the elderly or those with preexisting balance disorders. Ultimately, the focus should be on the Epley Maneuver as the primary treatment, with Meclizine used judiciously and only when necessary for severe symptoms, emphasizing the importance of follow-up to monitor for resolution or persistence of symptoms and to address any concerns about recurrence or falls risk.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The recommended dosage is 25 mg to 100 mg daily administered orally, in divided doses, depending upon clinical response.

The treatment plan of Meclizine 12.5 mg three times a day as needed (TID PRN) is within the recommended dosage range of 25 mg to 100 mg daily, and it is appropriate for a 56-year-old male patient diagnosed with Benign Paroxysmal Positional Vertigo (BPPV). The Epley Maneuver is also a suitable treatment for BPPV, and its use in conjunction with Meclizine is a reasonable approach 2. Key points to consider:

• The patient should be warned about the potential for drowsiness and advised to use caution when driving or operating machinery.
• Meclizine should be used with caution in patients with certain medical conditions, such as asthma, glaucoma, or enlargement of the prostate gland 2.

From the Research

Treatment Plan for Benign Paroxysmal Positional Vertigo (BPPV)

The treatment plan for a 56-year-old male patient diagnosed with BPPV includes the Epley Maneuver and medication with Meclizine 12.5 mg three times a day as needed (TID PRN). Key points to consider:

• The Epley Maneuver is a widely accepted treatment for BPPV, with studies showing its effectiveness in resolving vertigo symptoms and converting a positive Dix-Hallpike test to negative 3, 4, 5.
• The maneuver has been shown to be safe, with minimal adverse effects reported, such as nausea and cervical spine problems 3.
• Meclizine is an antihistamine commonly used to treat vertigo and dizziness, and its use in combination with the Epley Maneuver may help alleviate symptoms.

Efficacy of the Epley Maneuver

Studies have demonstrated the efficacy of the Epley Maneuver in treating BPPV:

• A systematic review of 11 randomized controlled trials found that the Epley Maneuver was effective in resolving vertigo symptoms and converting a positive Dix-Hallpike test to negative in patients with posterior canal BPPV 3.
• Another study found that the modified Epley Maneuver had a success rate of 93.4% in treating BPPV, with an average of 1.23 maneuvers required per patient 4.
• A systematic review of five controlled clinical trials found positive evidence for the use of the Epley Maneuver in treating BPPV, with significant improvements in objective and subjective outcomes 5.

Comparison with Other Treatments

Comparisons with other treatments, such as vestibular rehabilitation, have shown:

• The Epley Maneuver to be more effective than vestibular rehabilitation at 1-week follow-up, but with inconsistent evidence at 1-month follow-up 6.
• Repeated application of the Epley Maneuver may be beneficial for patients who do not respond to initial treatment, with cumulative success percentages ranging from 40% to 100% after multiple sessions 7.

Considerations for the Patient

Given the patient's diagnosis of BPPV and positive Dix-Hallpike test, the treatment plan of Meclizine 12.5 mg TID PRN and the Epley Maneuver is appropriate. Key considerations include:

• Monitoring the patient's response to treatment and adjusting the plan as needed.
• Providing instructions on how to perform the Epley Maneuver and any necessary follow-up care.
• Addressing any concerns or questions the patient may have about their treatment and prognosis.