What is the recommended treatment and dosage of Betahistine for Meniere's disease?

Betahistine Treatment for Meniere's Disease

The recommended treatment for Meniere's disease is betahistine at a standard initial dose of 48 mg daily in divided doses (16 mg three times daily), with treatment efficacy evaluated after 2-3 months. 1

Dosage and Administration

• Standard initial dose: 48 mg daily (16 mg three times daily)
• Dose range: 24-144 mg daily, depending on clinical response
• Administration: Take with food to minimize gastrointestinal side effects
• Doses should be spaced evenly throughout the day
• Treatment duration: Evaluate efficacy after 2-3 months 1

Efficacy for Different Symptoms

1. Vertigo attacks:

   • Most effective during intercritical phase to reduce number and severity of attacks (87% expert agreement) 2
   • Less effective during acute attacks; should be combined with vestibular suppressants during acute episodes 1, 2

2. Hearing function:

   • Some evidence suggests betahistine may help prevent/reverse hearing deterioration 3
   • Predictors of poor hearing response: age >47 years, initial hearing loss >38dB, and disease duration >1.4 years 3

3. Other symptoms:

   • Limited efficacy for tinnitus and ear fullness 2

Treatment Considerations

• Regular monitoring of vertigo, tinnitus, and hearing loss is essential to assess efficacy 1
• For patients with inadequate response after 2-3 months:
  • Consider dose adjustment (up to 144 mg daily) 1
  • Consider vestibular rehabilitation/physical therapy, especially for patients with nonusable hearing 1
  • Some evidence suggests combining with intratympanic dexamethasone may improve vertigo control 4

Formulations

• Standard immediate-release formulation: 16 mg three times daily
• Modified-release formulation: 48 mg once daily (shown to be non-inferior to standard formulation) 5

Contraindications and Precautions

• Use with caution in patients with:
  • Asthma
  • History of peptic ulcer disease
• Avoid in patients with pheochromocytoma 1

Side Effects

Common side effects are generally mild:

• Headache
• Balance disorders
• Nausea
• Nasopharyngitis
• Sensation of heat
• Eye irritation
• Palpitations
• Gastrointestinal symptoms 1

Important Considerations

• Despite widespread use, recent high-quality evidence suggests betahistine's efficacy in reducing vertigo attacks may not be superior to placebo 1
• The BEMED trial showed no significant differences between betahistine (48 mg/day or 144 mg/day) and placebo in reducing vertigo attacks after 9 months 1
• However, betahistine remains the mainstay of drug treatment for Meniere's disease due to its established safety profile and clinical experience 6

Treatment Algorithm

1. Start with betahistine 48 mg daily (16 mg TID)
2. Add vestibular suppressants only during acute attacks
3. Evaluate response after 2-3 months
4. If inadequate response:
   • Consider increasing dose (up to 144 mg daily) 1, 4
   • Add vestibular rehabilitation
   • Consider combination therapy with intratympanic dexamethasone for refractory cases 4
5. Once symptoms stabilize, consider gradual reduction or discontinuation 1