What are the best management options for a 73-year-old woman with anxiety and tinnitus, currently treated with Lexapro (escitalopram) 25 mg daily, with a recent tinnitus flare-up correlated with stress levels, and who has tried gabapentin without relief?

Management of Tinnitus in a 73-Year-Old Woman with Anxiety

For a 73-year-old woman with anxiety and tinnitus who has had a tinnitus flare-up despite Lexapro 25 mg daily and unsuccessful trial of gabapentin, benzodiazepines are recommended as the most effective treatment option, particularly when the tinnitus is correlated with stress levels.

Medication Options

Current Treatment Evaluation

• The patient is on escitalopram (Lexapro) 25 mg daily for anxiety with good response initially
• Recent tinnitus flare-up correlates with increased stress levels
• Gabapentin trial was unsuccessful
• Hearing aids have been ordered and will be available soon

Recommended Pharmacological Interventions

1. Benzodiazepines

   • Benzodiazepines have shown efficacy in treating severe disabling tinnitus, particularly when stress-related 1
   • Consider adding lorazepam 0.5-1 mg every 4 hours as needed when anxiety contributes to nausea/vomiting symptoms, which can be applied to anxiety-related tinnitus 2
   • Short-term use (2-4 weeks) is recommended to prevent dependence issues 3
   • Diazepam is often the drug of choice for episodic anxiety and can be given in single doses or very short courses (1-7 days) 3

2. SSRI Considerations

   • Current escitalopram dose (25 mg) exceeds typical target dose of 10-20 mg daily 4
   • SSRIs can rarely cause or exacerbate tinnitus as a side effect 5
   • Consider dose reduction of escitalopram to see if this improves tinnitus symptoms

3. Alternative Medication Options

   • Consider switching to sertraline (25-50 mg starting dose, up to 200 mg target dose) if escitalopram is suspected of contributing to tinnitus 4
   • Buspirone (15 mg daily initially, target 20-30 mg daily) may be beneficial for anxiety without worsening tinnitus 4
   • SNRIs like venlafaxine (37.5 mg daily initially, target 225 mg daily) or duloxetine (30 mg daily initially, target 60 mg daily) may be considered as alternatives 2, 4

Non-Pharmacological Approaches

1. Hearing Aids

   • Continue with plan for hearing aid fitting (scheduled for 8/21)
   • Hearing aids can provide significant relief for tinnitus associated with hearing loss

2. Behavioral Interventions

   • Cognitive Behavioral Therapy (CBT) is recommended as an adjunctive treatment 4
   • Focus on education about anxiety, behavioral goal setting, and cognitive restructuring to address negative thought patterns
   • Recommend 14 sessions over 4 months, each lasting 60-90 minutes 4

3. Stress Management Techniques

   • Since tinnitus correlates with stress levels, implement stress reduction strategies:
     • Progressive muscle relaxation
     • Mindfulness meditation
     • Deep breathing exercises
     • Regular physical activity if appropriate

Monitoring Plan

1. Regular Assessment

   • Evaluate response to treatment at 4 and 8 weeks using standardized tools 4
   • Monitor for side effects, particularly with benzodiazepines (sedation, falls risk)
   • Assess for changes in tinnitus severity with hearing aid use

2. Safety Considerations

   • Monitor for potential increased risk of falls with benzodiazepines in this 73-year-old patient
   • Limit benzodiazepine duration to prevent dependence
   • Continue EKG monitoring with current high-dose escitalopram

Common Pitfalls to Avoid

• Prolonged benzodiazepine use: Limit to short courses to prevent dependence 3
• Overlooking medication side effects: SSRIs like escitalopram can rarely cause or worsen tinnitus 5
• Relying solely on pharmacotherapy: Combining medication with behavioral interventions yields better outcomes 4
• Ignoring the stress-tinnitus connection: Address underlying anxiety as it correlates with tinnitus symptoms
• Expecting immediate results from hearing aids: It may take time for the patient to adapt and experience benefits