Is it safe to start prednisolone (corticosteroid) 40 mg for 7 days in a 50-year-old woman with giddiness, normal serum electrolytes, and calcium levels of 7.32 mg/dL, diagnosed with vestibular neuritis, and also taking calcium and vitamin D (cholecalciferol) 60,000 units for 4 weeks, and low-dose amitriptyline (tricyclic antidepressant) 10 mg for nighttime awakenings?

Management of Vestibular Neuritis with Prednisolone

Prednisolone 40 mg daily for 7 days is safe and recommended for a 50-year-old woman with vestibular neuritis, and should be taken with food to minimize gastrointestinal side effects. 1, 2, 3

Rationale for Prednisolone Use in Vestibular Neuritis

Vestibular neuritis is characterized by acute onset vertigo, nausea, and postural imbalance without hearing loss. It's the third most common cause of peripheral vestibular vertigo 2. The evidence strongly supports corticosteroid treatment:

• Methylprednisolone significantly improves recovery of peripheral vestibular function in patients with vestibular neuritis (62.4% improvement vs 39.6% with placebo) 4
• Earlier treatment (within 24 hours) results in better outcomes, with 100% of patients showing normal caloric test results at 3 months compared to only 58% when treated between 25-72 hours 3
• A short course of oral corticosteroids for 7-14 days with tapering dose is beneficial in reducing inflammation and improving outcomes 1

Administration Guidelines

• Timing: Take prednisolone with food to minimize gastrointestinal irritation 5
• Duration: The 7-day course is appropriate, consistent with guidelines that recommend short-term use 1
• Tapering: While your 7-day course is relatively short, consider tapering the dose over the last few days to minimize risk of adrenal suppression 6

Safety Considerations

The patient's profile indicates this treatment is safe:

• Normal serum electrolytes
• No contraindications like active infection, gastrointestinal bleeding, or uncontrolled diabetes
• Low calcium level (7.32) is not a contraindication but should be addressed

Concomitant Medications

1. Calcium and Vitamin D supplementation:

   • Appropriate and beneficial alongside prednisolone, especially with the patient's low calcium level (7.32)
   • No significant interaction between prednisolone and calcium/vitamin D 5
   • May help prevent corticosteroid-induced bone mineral density loss 5

2. Amitriptyline 10 mg:

   • Low-dose amitriptyline for nighttime awakenings is reasonable
   • No significant interaction with prednisolone
   • Monitor for potential additive side effects like dizziness or sedation 5

3. Oral Rehydration Solution (ORS):

   • Appropriate supportive care for maintaining hydration, especially if the patient has nausea

Monitoring and Follow-up

• Monitor for common side effects of prednisolone: increased appetite, fluid retention, mood changes, and elevated blood glucose 5
• Elderly patients may be more susceptible to corticosteroid-induced side effects, but the short course minimizes these risks 5
• ENT referral is appropriate for further evaluation of vestibular function

Additional Management Recommendations

• Consider vestibular rehabilitation exercises after the acute phase, as they have been shown to reduce dizziness and improve daily function when combined with corticosteroid treatment 7
• Patient education regarding the natural course of vestibular neuritis is important, as mild transitory episodes of dizziness may recur over 12-18 months 8
• Fall prevention counseling is recommended, especially during the acute phase 1

Potential Pitfalls

• Avoid prolonged use of vestibular suppressants as they can delay vestibular compensation 1
• Be aware that a small percentage of patients initially diagnosed with vestibular neuritis may have central nervous system disorders that can masquerade as peripheral vertigo 6
• Monitor for potential rare adverse effects of prednisolone including hypertension, hyperglycemia, and mood changes 5