Negative Impact of Vestibular Suppressant Drugs on Provocative Positional Tests of BPPV

Abstract

Aims: To study the impact of vestibular suppressant drugs (VSD) on provocative positional tests (PPT) in patients with benign paroxysmal positional vertigo (BPPV). Settings and Design: A prospective case-control observational study. Materials and Methods: Patients with a history suggestive of BPPV were tested for PPT. Patients with vertiginous symptoms and with nystagmus on PPT were classified as objective BPPV (O-BPPV, control group), while those without nystagmus with no alternate diagnosis were classified as subjective BPPV (S-BPPV, case group). Details of VSD treatment were noted in all the patients. In both groups, patients were instructed to discontinue VSD and were further assigned as the VSD and non-VSD subgroups. Patients were followed for 2 months with PPT every week. PPT positive patients were treated by vestibular rehabilitation maneuvers. Statistics: Student t-test with two-tailed, unpaired, was used for continuous scale and Chi-square test for categorical differences between the two groups. Results: 295 consecutive BPPV patients were enrolled in the study, 55 in the S-BPPV group and 240 in the O-BPPV group. Significantly higher proportion of patients in the S-BPPV group were on VSD at presentation, 80.00% vs. 53.75% (OR 2.52; 95% CI: 1.30–4.86), P = 0.006. In an unadjusted analysis of the S-BPPV group following discontinuation of VSD, PPT became positive in 79.54% of patients as compared to 18.19% in the non-VSD group (OR 35.0; 95% CI: 6.2–197.3), P < 0.001. Conclusion: A higher proportion of S-BPPV patients were receiving VSD in comparison to O-BPPV at the initial visit. The PPT converted positive four times higher after ceasing the VSD in S-BPPV patients. Study Design: Prospective case-control observational study.

Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta‐analysis of randomized controlled trials

“…In addition to a probable lack of therapeutic effect, some patients will have adverse effects from vestibular suppressants, especially older patients 14 . One “adverse” effect of using vestibular suppressants is that they can reduce the sensitivity of subsequent diagnostic maneuvers and interfere with later diagnosis 16–18 . Although our results did not find evidence of harm with vestibular suppressants, only one study reported adverse events without any noted outcomes.…”

“…Although the AGS focused on longer term use of medications rather than the single‐use ones in the ED, indirect evidence shows that patients often continue taking medications chronically that were initially meant for short‐term symptomatic management 15 . In addition to direct adverse effects, data suggest that use of vestibular suppressant medications in patient with BPPV reduces the frequency of nystagmus, which can interfere with confident diagnosis 16–18 …”

Benign paroxysmal positional vertigo: A practical approach for emergency physicians

“…The American Geriatric Society has a strong recommendation against meclizine use in older individuals, due to its anticholinergic side effects 47 . Although vestibular suppressants may help with the nausea, they do not treat the underlaying pathology of BPPV, have harmful side effects, and may reduce the sensitivity of diagnostic maneuvers 36,37,48 . In selected patients (those who are very nervous about having positional testing or very symptomatic with it), medication treatment prior to the positional testing and repositioning may be considered.…”

“…This can also happen due to the technique of the test if the patient is moved too slowly to the lying down position or does not have head tilt back of about 20 degrees. The incidence of this phenomenon, called “subjective BPPV,” from four studies ( N = 1077) ranged between 15% and 24% of patients with suspected BPPV 35–38 . In this group, although the diagnosis cannot be considered definite, many patients will improve after an Epley maneuver or other CRM 35,37,38 .…”

“…The incidence of this phenomenon, called "subjective BPPV," from four studies (N = 1077) ranged between 15% and 24% of patients with suspected BPPV. [35][36][37][38] In this group, although the diagnosis cannot be considered definite, many patients will improve after an Epley maneuver or other CRM. 35,37,38 Because one cannot be as confident of the diagnosis in the absence of nystagmus, it highlights the importance of selecting patients on whom to use the DHT.…”