Doxycycline Does Not Cause Hearing Loss
Doxycycline is not associated with ototoxicity and does not require any hearing-related monitoring or precautions. 1
Evidence from Guidelines
The tetracycline class, including doxycycline, is consistently excluded from lists of ototoxic antibiotics across multiple authoritative guidelines:
The American Thoracic Society and Infectious Diseases Society of America comprehensively reviewed drug toxicities for respiratory infections and identified aminoglycosides (streptomycin, amikacin, tobramycin) and macrolides (azithromycin, clarithromycin) as causing hearing loss, but made no mention of tetracyclines causing ototoxicity 2
The British Thoracic Society guidelines for NTM disease specifically list azithromycin as causing "tinnitus and hearing loss (particularly with higher doses in elderly patients)" 2, yet when discussing tetracyclines (doxycycline, minocycline), only gastrointestinal disturbance, photosensitivity, rash, hyperpigmentation, and central nervous system effects (dizziness, vertigo with minocycline) are mentioned—no hearing loss 2
The American Academy of Dermatology guidelines for acne management note that minocycline causes "tinnitus, dizziness, and pigment deposition" while doxycycline is "more frequently associated with gastrointestinal disturbances" and photosensitivity, but neither tetracycline is associated with hearing loss 2
Contrast with Truly Ototoxic Antibiotics
To understand why doxycycline is safe, it helps to recognize which antibiotics actually cause hearing damage:
Aminoglycosides (High Risk - Permanent Damage)
- Cause dose-dependent, irreversible sensorineural hearing loss affecting high frequencies first 2
- Require baseline audiometry before treatment and monthly monitoring during therapy 2, 3
- Ototoxicity occurred in 32 of 87 patients (37%) in one prospective study, associated with older age, duration of treatment, and cumulative dose 2
- Patients must be instructed to stop immediately if tinnitus, vertigo, or hearing loss develops 2, 3
Macrolides (Moderate Risk - Usually Reversible)
- Cause dose-dependent, reversible sensorineural hearing loss that typically resolves within 6-14 days after discontinuation 2
- Azithromycin caused hearing decrements in 25% of COPD patients (vs 20% placebo) in one trial, though criteria may have overestimated true incidence 2
- Patients with pre-existing hearing loss should be counseled about potential for further, almost always reversible, deterioration 2
Doxycycline (No Risk)
- No baseline audiometry required 1
- No hearing assessments during treatment needed 1
- No specific counseling about hearing loss risk necessary 1
Clinical Implications for Prescribing
When prescribing doxycycline, focus your side effect counseling on the actual risks:
- Photosensitivity (more common than with minocycline) 2
- Gastrointestinal upset (nausea, vomiting, diarrhea—can be reduced by taking with food) 2
- Esophageal irritation (take with adequate water, avoid lying down immediately after)
- Contraindications in pregnancy and children under 8 years (tooth discoloration, bone growth effects) 1
Safe Alternative in Patients with Hearing Loss
Doxycycline can be used as a safe alternative to ototoxic agents in patients with pre-existing hearing loss, without concern for ototoxicity. 1 This makes it particularly valuable when treating infections in:
- Elderly patients with age-related hearing loss
- Patients previously exposed to aminoglycosides or cisplatin
- Patients with baseline hearing impairment who require antibiotic therapy
Common Pitfall to Avoid
Do not confuse doxycycline with minocycline's vestibular side effects. While minocycline can cause dizziness and vertigo (central nervous system effects, not true ototoxicity) 2, doxycycline does not share this property and causes neither vestibular symptoms nor hearing loss.