What medications can cause tinnitus (ringing in the ears)?

Medications That Can Cause Tinnitus (Ringing in the Ears)

Many medications can cause tinnitus as an adverse effect, with ototoxic drugs like aminoglycosides, platinum-based chemotherapy agents, and certain NSAIDs posing the highest risk. 1, 2, 3

High-Risk Medications

Antibiotics

• Aminoglycosides (gentamicin, streptomycin, kanamycin, amikacin)
  • Cause irreversible damage to the vestibular branch of the eighth cranial nerve
  • Risk increases with renal impairment, prolonged therapy, and higher doses 3
  • Can cause permanent hearing loss even after discontinuation

Chemotherapeutic Agents

• Platinum compounds
  • Cisplatin: Increases risk of tinnitus by 5.53 times compared to non-ototoxic medications 4
  • Carboplatin: Increases risk by 3.75 times 4
  • Ototoxicity occurs in up to 31% of patients receiving a single dose of cisplatin 50 mg/m² 2
  • Damage typically affects high-frequency hearing first (4,000-8,000 Hz) 2

Anti-inflammatory Drugs

• NSAIDs (aspirin, ibuprofen, naproxen)
  • Tinnitus from NSAIDs is typically reversible and may indicate high medication blood levels 1
  • More common with higher doses and prolonged use

Moderate-Risk Medications

Diuretics

• Loop diuretics (furosemide, bumetanide)
• Thiazide diuretics (hydrochlorothiazide) 1

Cardiovascular Medications

• Anti-arrhythmics (amiodarone, dronedarone) 1
• Calcium channel blockers (amlodipine, diltiazem, nifedipine) 1
• ACE inhibitors 1

Other Notable Medications

• Macrolide antibiotics (azithromycin, erythromycin) 1
• Antipsychotics and atypical antipsychotics 1
• Antimalarials 1
• Phosphodiesterase-5 inhibitors 1

Risk Factors for Medication-Induced Tinnitus

1. Pre-existing conditions:

   • Renal impairment (reduces drug clearance) 2, 3
   • Pre-existing hearing loss 1
   • Advanced age 2, 3

2. Treatment factors:

   • High cumulative doses 2, 3
   • Prolonged treatment duration 2, 3
   • Concomitant use of multiple ototoxic medications 1

3. Patient-specific factors:

   • Dehydration (increases drug concentration) 5
   • Genetic predisposition (e.g., variants in the TPMT gene) 2

Clinical Presentation and Monitoring

• Tinnitus may be unilateral or bilateral
• May be accompanied by hearing loss, vertigo, or balance problems
• Can persist even after medication discontinuation
• For high-risk medications (especially cisplatin and aminoglycosides):
  • Baseline audiometric testing before treatment
  • Regular monitoring during treatment
  • Follow-up testing after completion 2

Management of Medication-Induced Tinnitus

1. When tinnitus develops:

   • Evaluate medication list for potential causes
   • Consider dose reduction when possible
   • Weigh benefits versus risks of continuing medication
   • Consider alternative medications with lower ototoxicity risk

2. Prevention strategies:

   • Use lowest effective dose of ototoxic medications
   • Monitor renal function in patients receiving aminoglycosides or cisplatin
   • Avoid concurrent use of multiple ototoxic medications
   • Ensure adequate hydration during treatment 5

Important Caveats

• Tinnitus from NSAIDs and some medications may be reversible upon discontinuation 1
• Tinnitus from aminoglycosides and platinum compounds is often permanent 2, 3
• Pulsatile tinnitus requires different evaluation as it may indicate vascular abnormalities 1, 6
• Patients with pre-existing hearing loss are at higher risk for developing medication-induced tinnitus 1

Remember that medication-induced tinnitus should be distinguished from other causes of tinnitus, including age-related hearing loss, noise exposure, ear infections, and neurological disorders 6, 7.