Would you consider using prednisone as abortive therapy for a flare-up of dizziness in Meniere's (Inner Ear) disease?

Prednisone as Abortive Therapy for Dizziness Flare-ups in Meniere's Disease

Intratympanic steroids may be offered for acute vertigo attacks in Meniere's disease, but oral prednisone is not recommended as an abortive therapy for dizziness flare-ups in Meniere's disease based on current clinical guidelines. 1

Evidence for Steroid Use in Meniere's Disease

• The 2020 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guideline for Meniere's disease specifically addresses intratympanic (IT) steroid therapy but does not recommend oral steroids for acute attacks 1
• IT steroid therapy has shown some benefit for vertigo control (85-90% improvement vs 57-80% with placebo or conventional therapy) 1
• IT steroid therapy appears to have less risk of treatment-associated hearing loss (0-8%) compared to IT gentamicin (12.5-15.4%) 1
• Systemic steroids are primarily considered for bilateral Meniere's disease, particularly when an autoimmune basis is suspected, but not specifically as abortive therapy 2

Management of Acute Vertigo Attacks

• The AAO-HNS guideline recommends offering a limited course of vestibular suppressants for acute vertigo attacks in Meniere's disease 1
• Vestibular suppressants with anticholinergic, anti-emetic, and vestibular sedative effects are the established first-line treatment for controlling acute attacks 2
• Benzodiazepines may be used to alleviate anxiety during acute attacks 2
• There is insufficient evidence supporting the use of systemic steroids for acute vertigo attacks in Meniere's disease 1

Treatment Algorithm for Meniere's Disease

1. First-line for acute attacks:

   • Vestibular suppressants (anticholinergics, antiemetics) 2
   • Benzodiazepines for anxiety management during attacks 2

2. For prevention and long-term management:

   • Lifestyle modifications (low salt diet, stress avoidance) 3
   • Diuretics 3, 2
   • Betahistine (commonly used in Europe) 2

3. For refractory cases:

   • Intratympanic steroid therapy may be considered 1
   • Intratympanic gentamicin for patients not responsive to nonablative therapy 1
   • Surgical options for severe cases not responding to medical management 3

Important Considerations

• A 2023 Cochrane review found very uncertain evidence for systemic pharmacological interventions in Meniere's disease, including corticosteroids 4
• Another 2023 Cochrane review on intratympanic corticosteroids found they may slightly reduce the frequency of vertigo episodes (approximately 1.5 fewer days per month affected by vertigo), but the evidence was of low certainty 5
• The etiology of Meniere's disease remains unclear, making it difficult to establish definitive treatment protocols 6
• Steroid therapy has been suggested for status migrainosus (severe, continuous migraine), but there are no good studies documenting its efficacy in the treatment of acute attacks 1

Conclusion

While intratympanic steroids may be considered for Meniere's disease, oral prednisone is not specifically recommended as an abortive therapy for dizziness flare-ups based on current clinical guidelines. The standard approach for acute attacks remains vestibular suppressants and symptomatic management, with more invasive options reserved for refractory cases.