Serc (Betahistine) for Meniere's Disease
Serc (betahistine) is used for Meniere's disease, not for benign paroxysmal positional vertigo (BPPV). 1
Primary Indication
Betahistine is specifically indicated for maintenance therapy in Meniere's disease to reduce the frequency and severity of vertigo attacks during the intercritical phase. 1 The American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly recommend clinicians may offer betahistine for maintenance therapy to reduce symptoms or prevent Meniere's disease attacks. 1
Role in BPPV vs Meniere's Disease
In BPPV, betahistine is NOT a primary treatment but may only be used as an adjunct to reduce residual dizziness after successful canalith repositioning maneuvers or to reduce vertigo severity during the maneuvers themselves. 2
In Meniere's disease, betahistine serves as a cornerstone maintenance medication with demonstrated efficacy in reducing vertigo attack frequency and severity during the intercritical phase. 1, 3
Standard Dosing Protocol
Start with 48 mg daily (either as 24 mg twice daily or a single 48 mg modified-release tablet). 4, 5
Minimum treatment duration of 3 months is required to properly evaluate therapeutic efficacy. 4, 5
Reassess at 6-9 months: if no improvement occurs by this time, discontinue betahistine as continued therapy is unlikely to provide benefit. 4, 5, 6
Higher doses (144 mg/day) show no advantage over the standard 48 mg/day dose. 4, 5
Important Evidence Caveat
The American Academy of Otolaryngology-Head and Neck Surgery explicitly states they cannot make a definitive recommendation for betahistine due to conflicting evidence. 4, 5 The high-quality BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks over 9 months, contradicting older studies. 4, 5
Contraindications and Safety
Relative contraindications: active asthma and peptic ulcer disease (use with caution). 4, 5, 6
Common side effects: headache, balance disorder, nausea, upper gastrointestinal symptoms, nasopharyngitis, feeling hot, eye irritation, and palpitations. 4, 5, 6
Enhanced Efficacy Strategy
Combining intratympanic steroids with oral betahistine may improve outcomes, with 73% vertigo control versus 44% with intratympanic steroids alone. 1, 4, 6 This combination approach should be considered for patients with inadequate response to betahistine monotherapy.
Clinical Bottom Line
Betahistine is for Meniere's disease maintenance therapy, not BPPV primary treatment. 1, 2 Despite guideline inclusion, the highest quality evidence (BEMED trial) shows no superiority over placebo, so realistic expectations should be set with patients. 4, 5 For refractory cases, intratympanic gentamicin provides 70-87% complete vertigo control, though with 12.5-15.4% hearing loss risk. 4, 6