From the Guidelines
The next step in managing this 65-year-old male with persistent vertigo despite current treatments would be to refer him to an otolaryngologist (ENT specialist) for further evaluation and possible additional diagnostic testing. The patient should continue his current medications while awaiting this consultation. The specialist may order tests such as videonystagmography (VNG), audiometry, or MRI imaging to better characterize the underlying cause of his persistent symptoms. Conditions such as Meniere's disease, vestibular neuritis, or acoustic neuroma need to be ruled out given his age and persistent symptoms 1. The ENT may consider alternative medications such as betahistine (8-16mg three times daily) or a trial of a different antivertigo medication like dimenhydrinate (50mg every 4-6 hours as needed). If Meniere's disease is suspected, a low-salt diet (less than 2g sodium daily) and a diuretic like hydrochlorothiazide (12.5-25mg daily) might be recommended. The persistence of symptoms despite multiple interventions suggests either an incomplete diagnosis or a condition requiring more specialized management. The addition of tinnitus to vertigo raises concern for inner ear pathology that would benefit from specialist evaluation rather than continuing the current ineffective regimen. Given the complexity of the case and the need for specialized care, referral to an ENT specialist is the most appropriate next step, as emphasized by the clinical practice guidelines for benign paroxysmal positional vertigo and Meniere's disease 1.
Some key points to consider in the management of this patient include:
- The importance of a thorough diagnostic evaluation to rule out other causes of vertigo and tinnitus, such as vestibular migraines or inner ear disorders 1.
- The potential benefits of alternative medications, such as betahistine or dimenhydrinate, in managing vertigo symptoms 1.
- The need for patient education and counseling on the risks and benefits of different treatment options, as well as the importance of follow-up care to monitor symptoms and adjust treatment as needed 1.
- The consideration of lifestyle modifications, such as a low-salt diet, to help manage symptoms and prevent exacerbations 1.
Overall, the management of this patient requires a comprehensive and multidisciplinary approach, involving both medical and surgical specialists, to ensure the best possible outcomes and quality of life.
From the FDA Drug Label
17 PATIENT COUNSELING INFORMATION
Administration Instructions: Advise patients that the tablets must be swallowed whole, but chewable tablets must be chewed or crushed completely before swallowing [see Dosage and Administration (2. 1)]. Adverse Reactions: Advise patients that meclizine hydrochloride tablets may cause anaphylactic reaction, drowsiness, dry mouth, headache, fatigue, vomiting and, on rare occasions, blurred vision [see Warnings and Precautions (5. 1), Adverse Reactions (6)]. Inform patients that meclizine hydrochloride tablets may impair their ability to engage in potentially dangerous activities, such as operating machinery or vehicles Concomitant Drug Interactions: Advise patients regarding medications that should not be taken in combination with meclizine hydrochloride tablets or that may necessitate increased monitoring [see Drug Interactions (7.1,7. 2)]. Inform patients that alcohol may increase adverse reactions. Concurrent Medical Conditions: Advise patients to notify their healthcare provider about all of their medical conditions, including if they are pregnant or plan to become pregnant or if they are breastfeeding [see Warnings and Precautions (5.2), Use in Specific Populations (8.1,8. 2)].
The patient has already been taking meclizine and prednisone, and has undergone vestibular therapy and at-home exercises. The next step would be to consider an ENT referral as previously suggested, since the patient's symptoms have not totally resolved with the current treatment plan 2.
From the Research
Management of Persistent Vertigo
The patient's symptoms of dizziness, vertigo, and intermittent tinnitus have not fully resolved with meclizine and prednisone treatment. Considering the patient's history and current symptoms, the next steps in management could include:
- Re-evaluation of the patient's condition to determine the underlying cause of vertigo, as the current treatment has not led to complete resolution of symptoms 3
- Consideration of alternative treatments, such as vestibular rehabilitation therapy, which has been shown to be effective in improving symptoms of vertigo 4
- Evaluation of the patient's response to meclizine, as studies have shown that diazepam and meclizine are equally effective in treating vertigo, and consideration of alternative medications if necessary 5
Role of Corticosteroids in Vertigo Management
The use of corticosteroids, such as prednisone, in the management of vertigo is controversial, with some studies suggesting a beneficial effect 6 and others finding insufficient evidence to support their use 7. The patient's current treatment with prednisone may need to be re-evaluated based on the latest evidence.
Vestibular Rehabilitation and Exercises
The patient has been advised to perform at-home vertigo exercises and has been referred for vestibular therapy. These exercises and therapies have been shown to be effective in improving symptoms of vertigo and should be continued as part of the patient's management plan 4.
Further Evaluation and Referral
If the patient's symptoms persist or worsen, further evaluation and referral to a specialist, such as an ENT specialist, may be necessary to determine the underlying cause of vertigo and develop an effective treatment plan 3.