Dietary Modification
Mia Miller, MD, a neurotologist with the House Clinic in Los Angeles, said counseling on dietary matters with Ménière’s patients can be tricky. Research has found that those with possible disease are more compliant with salt restrictions than those with definite disease (possibly because they’re more motivated to prevent more serious disease), but both groups have been found to show improvement in some studies.
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March 2019Ultimately, though, the quality of the evidence is low. “There are not a lot of studies that are large enough, or randomized, to evaluate the effectiveness of sodium restriction,” she said. While some guidelines recommend keeping sodium intake to a very low level at 1,000 mg per day, some clinicians advocate a “no salt added” approach so that patients at least avoid heavily salted foods.
One study found that fewer than half of patients had been given written dietary guidelines, and while patients said following low salt or caffeine diets was feasible, they had trouble naming appropriate foods within those diets (Otol Neurotol. 2013;34:1438–1443). “This shows how difficult dietary counseling can be,” Dr. Miller said. “It would be good to give written sodium intake guidelines so people at least know what you’re trying to counsel them to do.”
She added that some physicians refer to a nutritionist if a patient is confused about what they should be eating, and she refers to an allergist if she thinks it could help control symptoms.
Systemic Medications
Dr. Blakley said there is no clear path for using systemic medications in treating Ménière’s. He ticked off a series of drug types for which there is insufficient or a low level of evidence: There is not enough evidence on diuretics, studies on antivirals have primarily not suggested efficacy, and he has found no strong endorsements for allergy treatments.
Betahistine is an interesting case, he added. There is evidence that it might reduce the number of vertigo attacks, but the certainty of the evidence is low (Medwave. 2017;17:e7068). “It doesn’t have significant side effects; in fact, this is why many of us think that it’s a placebo drug,” Dr. Blakley said. “It started off as a dose of 4 mg, and they’re supposed to get 8, then 16, then 32,” and even 48 mg. “I don’t know of any physiologic drug that you could increase the dose by that much and still have no side effects. …. There are certainly a lot of people who just love that drug. And it’s cheap, it’s safe, so why not, if they like it?”
The ambiguity might be a benefit because it forces clinicians to tailor according to the situation, he said. “I think we have many treatments, all with not very good data,” he said. “The factory model, I think, does not work; there isn’t one step that leads to another, and then do this, and so forth. There is a lot of variety and I think that may be a good thing. It allows us to consider cost, safety, and patient preferences.”
Betahistine is unavailable in the U.S.—though it is available in Canada, where Dr. Blakley practices—and he was asked whether he though U.S. clinicians should push for its availability. He said he didn’t think it’s an “emergency.” Even though the case for it may not be strong, he said, “I think it may be reasonable. There are certainly a lot of people who would use it.”