Chlorthalidone vs HCTZ for Ménière's Disease
Direct Answer
Neither chlorthalidone nor hydrochlorothiazide (HCTZ) has proven superiority over the other for Ménière's disease, and the evidence for diuretics in general remains very uncertain. The 2020 American Academy of Otolaryngology-Head and Neck Surgery guidelines state there is no specific preference for one diuretic agent over another for Ménière's disease 1. However, if you must choose a diuretic, use the one you are most familiar with for monitoring electrolyte complications, as both carry similar risks in this context.
Evidence Quality and Guideline Recommendations
Diuretics as a Class for Ménière's Disease
The AAO-HNS 2020 guidelines provide only an "option" level recommendation (the weakest recommendation level) for diuretics in Ménière's disease, based on Grade C evidence 1.
A 2023 Cochrane systematic review found very low-certainty evidence for diuretics in Ménière's disease, with only two RCTs identified (one using isosorbide, another using amiloride/HCTZ combination), and neither study assessed serious adverse events 2.
The guideline panel explicitly states: "There is no specific preference for one agent over another" when discussing diuretic options for Ménière's disease 1.
No Specific Comparison Studies
No studies directly compare chlorthalidone to HCTZ specifically for Ménière's disease 2.
The limited diuretic evidence in Ménière's disease comes from studies using various agents (isosorbide, amiloride/HCTZ combinations), none specifically comparing the two thiazide-type diuretics in question 2.
Clinical Decision Algorithm
When Considering Diuretics for Ménière's Disease:
First-line approach should be dietary sodium restriction (1500-2300 mg daily) before pharmacotherapy 1.
If diuretics are warranted, select based on:
If using HCTZ: Standard dosing would be 25-50 mg daily based on hypertension literature 3.
If using chlorthalidone: Standard dosing would be 12.5-25 mg daily 3.
Critical Monitoring Requirements
Monitor electrolytes (especially potassium and magnesium) within 4 weeks of initiation 3.
Hypokalemia is dose-related with both agents and can contribute to ventricular ectopy 3.
Chlorthalidone has a longer half-life and may accumulate more, increasing hypokalemia risk even at lower equivalent doses 3.
Important Caveats
Evidence Limitations
The entire evidence base for diuretics in Ménière's disease is weak, with the Cochrane review unable to conduct meta-analyses due to heterogeneity and poor study quality 2.
No studies adequately assessed serious adverse events from diuretic use in Ménière's patients 2.
The 2020 guidelines acknowledge that while some studies showed improvement in vertigo with diuretics, the overall quality was insufficient for strong recommendations 1.
Contraindications Apply Equally
- Both agents are contraindicated in patients with:
Alternative Considerations
Betahistine may be considered as an alternative to diuretics, though the 2020 BEMED trial showed no significant difference from placebo 1.
International consensus recommends diuretics and betahistine as first-line conservative medical treatment, but acknowledges the evidence base is limited 4.
Practical Bottom Line
Since no evidence differentiates these agents for Ménière's disease specifically, default to HCTZ if you must use a diuretic, as it has a lower hypokalemia risk profile 3 and you can use standard 25-50 mg daily dosing 3. However, recognize that the evidence supporting any diuretic for Ménière's disease is very uncertain 2, and dietary modification with sodium restriction should be the foundation of treatment 1.