What is the comparison between Stemetil (prochlorperazine) and Betaserc (betahistine) for treating Meniere's disease symptoms?

Stemetil vs Betaserc for Meniere's Disease

For Meniere's disease maintenance therapy, betahistine (Betaserc) may be offered as an option, while prochlorperazine (Stemetil) should be reserved only for acute vertigo attacks—not for maintenance treatment. 1

Role of Each Medication

Betahistine (Betaserc) - Maintenance Therapy

• Betahistine is specifically indicated for maintenance therapy to reduce symptoms or prevent Meniere's disease attacks, though the evidence remains equivocal. 1
• The American Academy of Otolaryngology-Head and Neck Surgery offers betahistine as an option (not a strong recommendation) based on observational studies, with the caveat that the most recent high-quality BEMED trial showed no significant difference between betahistine and placebo. 2
• Start with 48 mg daily (either 24 mg twice daily or 48 mg modified-release once daily) and continue for at least 3 months to evaluate efficacy. 3
• If no improvement occurs after 6-9 months, discontinue betahistine as continued therapy is unlikely to be beneficial. 3
• The mechanism involves histamine H1 receptor weak agonism and H3 receptor antagonism, potentially increasing vasodilation to the inner ear and affecting central vestibular compensation. 1, 4

Prochlorperazine (Stemetil) - Acute Symptom Control Only

• Prochlorperazine is an antivertigo medication used for acute vertigo symptoms, not for maintenance therapy. 1
• It functions as an antiemetic and vestibular suppressant during acute attacks but does not prevent future episodes. 1
• Critical caveat: Vestibular suppressants like prochlorperazine can hamper vestibular compensation when used chronically, making them inappropriate for long-term management. 4

Evidence Quality Assessment

The evidence for betahistine remains controversial:

• A 2016 Cochrane review suggested a 56% reduction in vertigo with betahistine versus placebo. 2
• However, the more recent and higher-quality BEMED trial (the most rigorous double-blind RCT to date) found no significant difference between betahistine and placebo, leading to the inability to make a definitive recommendation. 2, 3
• Despite this, the American Academy of Otolaryngology-Head and Neck Surgery still offers betahistine as an option based on the balance of benefits and harms, recognizing variable patient responses. 1

Safety Profiles

Betahistine Contraindications and Side Effects

• Absolute contraindication: pheochromocytoma 3
• Use with caution in asthma and peptic ulcer disease 2, 3
• Common side effects: headache, balance disorder, nausea, nasopharyngitis, feeling hot, eye irritation, palpitations, upper GI symptoms 2
• No routine laboratory monitoring required 3

Prochlorperazine Considerations

• Sedating effects that interfere with vestibular compensation 4
• Extrapyramidal side effects with prolonged use
• Not appropriate for chronic maintenance therapy 1

Clinical Algorithm

For active Meniere's disease with recurrent vertigo attacks:

1. Acute attack management: Use prochlorperazine (Stemetil) for immediate symptom relief during acute vertigo episodes 1

2. Maintenance therapy: Consider betahistine (Betaserc) 48 mg daily for at least 3 months, recognizing that response is variable and evidence is equivocal 1, 3

3. Reassess at 6-9 months: If no improvement, discontinue betahistine and consider alternative therapies (diuretics, intratympanic gentamicin, or surgical options) 3

4. Never use prochlorperazine chronically as it impairs vestibular compensation and does not prevent future attacks 4

Key Pitfall to Avoid

The most common error is using vestibular suppressants like prochlorperazine for chronic maintenance therapy. These medications should only be used during acute attacks, as chronic use prevents the central nervous system from compensating for vestibular dysfunction and perpetuates disability. 4