Can These Medications Cause Ear Pain?
None of these four medications—losartan, hydrochlorothiazide, clonidine, or alendronate—are established causes of otalgia (ear pain) based on current clinical guidelines and high-quality evidence.
Hydrochlorothiazide and Hearing Disorders
While hydrochlorothiazide does not typically cause ear pain, there is emerging evidence of a potential association with hearing disorders:
- A 2018 case series identified 94 reports of hearing disorders associated with hydrochlorothiazide in the WHO global adverse drug reaction database, with a median time to onset of 3 days and reversibility in 66.7% of cases 1
- The reaction was marked as "serious" in 36% of cases, and in 26 cases, hearing disorder occurred following hydrochlorothiazide as the sole medication 1
- However, this represents hearing loss or vestibular symptoms rather than otalgia specifically 1
- Loop diuretics like furosemide are well-established ototoxic agents, but thiazide diuretics like hydrochlorothiazide have a different mechanism and lower ototoxic risk 2
Losartan Safety Profile
- The most common adverse effect of losartan is dizziness, with an overall withdrawal rate due to adverse effects (2.3%) lower than placebo (3.7%) 3
- Postmarketing surveillance has identified angioedema as a rare but serious adverse effect, but ear pain is not documented 3
- The ACC/AHA hypertension guidelines do not list otalgia among the adverse effects of ARBs like losartan 4
Alendronate Adverse Effects
- Alendronate's adverse events are predominantly upper gastrointestinal, including abdominal pain, nausea, dyspepsia, and esophageal reactions—not otalgia 5
- Musculoskeletal pain is reported but refers to bone/joint pain, not ear pain 5
- The ASCO osteoporosis guidelines discuss osteonecrosis of the jaw as a rare serious adverse effect of bisphosphonates, but this is distinct from otalgia 4
Clonidine Considerations
- Clonidine is not mentioned in any of the provided evidence as causing ear pain
- The ACC/AHA guidelines list clonidine among secondary antihypertensive agents but do not associate it with otalgia 4
Clinical Approach to Ear Pain in Patients on These Medications
When a patient on these medications presents with ear pain, consider:
- Primary otalgia from otitis media or otitis externa is far more common than drug-induced ear pain 6
- Secondary otalgia from temporomandibular joint syndrome, dental infections, or referred pain from other structures is more common in adults 6, 4
- Examine the ear with pneumatic otoscopy to identify primary causes like acute otitis media or acute otitis externa 4
- In patients over 50 with risk factors (smoking, alcohol use, diabetes), consider serious causes like temporal arteritis or malignancy that may require imaging or ENT consultation 6
Important Caveat
If ear pain develops in a patient taking hydrochlorothiazide along with other hearing symptoms (tinnitus, hearing loss, vertigo), consider hydrochlorothiazide-associated hearing disorder and evaluate for medication discontinuation 1. However, isolated otalgia without hearing changes is unlikely to be drug-related and warrants standard evaluation for primary or secondary causes 4.