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26th July 2022
Antihistamines are able to provide a greater level of symptom relief, 2 hours post-dose in patients with vertigo in comparison to benzodiazepines. However, neither class of drugs seems to be better than placebo after only one week. These were the key findings from a systematic review and meta-analysis by researchers from the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, US.
Vertigo is a symptom of vestibular dysfunction and described as a sensation of motion, most commonly rotational motion. The term dizziness is non-specific but usually refers to a sense of disorientation with vertigo being a subtype of dizziness. The sensation of dizziness is common condition and affects about 15% to 20% of adults annually and vestibular vertigo accounts for about a quarter of dizziness cases with an annual prevalence of 5%. Pharmacological treatments for the management of vertigo are referred to as vestibular suppressants and there are a wide of drug classes such as anticholinergics (scopolamine), antihistamines (cinnarizine), benzodiazepines (clonazepam) and dopamine receptor antagonist (prochlorperazine) and histamine-1 receptor antagonists (betahistine). In a 2017 updated clinical practice guideline, it was recommended that benzodiazepines and/or antihistamines could be used in the management of one of the most common forms of vertigo, benign paroxysmal positional vertigo. Despite this, there is an absence of comparative data for these two drug classes.
As a result, for the present study, the US team undertook a systematic review and meta-analysis to assess the efficacy of both drug classes in the management of acute vertigo due to any underlying cause. The team searched for randomised trials which included any antihistamine or benzodiazepine compared with an active comparator, placebo or no intervention in patients with acute vertigo and which had lasted for less than 2 weeks. The primary outcome of interest was the change in a 10 or 100-point vertigo or dizziness visual analogue scale (VAS) score at 2 hours post-treatment. Secondary outcomes included change in nausea VAS score at 2 hours and resolution of vertigo after one week and a month.
Antihistamines and improvement in vertigo scores
A total of 27 trials met the inclusion criteria, of which, 17 with 1586 participants were included in the meta-analysis.
For the primary outcome, 7 trials with 802 were included. Antihistamines were associated with a 16.1-point (95% CI 7.2 – 25) greater decrease in mean VAS vertigo scores compared to benzodiazepines. However, when compared to other active treatments, antihistamines performed to a similar extent (mean difference = 7.4, 95% CI -1.12 to 15.8).
For the secondary outcomes, after one week, there was no evidence to suggest a higher likelihood of complete symptom resolution from antihistamines (relative risk, RR = 1.03, 95% CI 0.56 – 1.89) or after 4 weeks. Similarly, the improvement with benzodiazepines was no better than placebo after one or 4 weeks.
The authors concluded that there was moderately strong evidence to show that single dose antihistamines provided better relief of vertigo symptoms after 2 hours than benzodiazepines. Furthermore, the evidence did not support an association between benzodiazepine use with an improvement in acute vertigo.
Hunter BR et al. Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-analysis JAMA Neurol 2022
28th May 2021
Sleep disturbances are a common problem that can manifest in at least three different ways, e.g., difficulties in getting to sleep, remaining asleep or early morning awakening. There are several prescription treatments available for sleep disturbance including benzodiazepines, Z-drugs (e.g., zopiclone, zolpidem) and sedating antidepressants such as trazodone. While these medicines are only recommended for short-term use, for some patients, the chronic nature of the condition invariably results in continued use of treatment, either intermittently or regularly, for extended periods of time. In an effort to examine the effects of sleep medicines on patient-reported measures of sleep disturbance, a team from the Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, US, set out to examine the impact of sleep medicines among a cohort of midlife women. Eligible participants were drawn from the Study of Women’s Health Across the Nation (SWAN), which is an ongoing longitudinal study examining the biological and psychological changes that occur during the menopause transition. On an annual basis, women were asked to self-report on three aspects of sleep: difficulty initiating, frequent awakening and early morning awakening and anyone who reported on these disturbances at least once, were eligible for inclusion in the study. Women were asked about their sleep medication during each study visit and women were asked, using a 5-point Likert scale, to report their level of difficulty to each of the three sleep aspects and the authors also included a matched cohort of non-sleep medicine users. Furthermore, as sleep disturbances may arise because of depression, anxiety and pain, individuals also completed questionnaires to identify the impact of each of these factors.
The study included 238 women who had an initial prescription for sleep medication and who were matched to 447 non-users. There were no significant differences between the two groups with respect to depression, anxiety or pain scores. The mean age of those using sleep medicines was 49.5 years and at baseline, the mean score for initiating sleep was 2.7, waking frequently 3.8 and early morning wakening 2.8. Among non-users, the corresponding mean values were similar; 2.6, 3.7 and 2.7 respectively. After 1 year of use, the mean scores among sleep medicine users were 2.6 (initiating sleep) vs 2.3 (non-users), 3.6 (frequent wakening) vs 3.5 (non-users) and 2.8 (early morning wakening) vs 2.5 (non-users) and none of these differences were statistically significant. In addition, there was no difference in mean scores between the two main classes of sleep medicines, benzodiazepines and Z-drugs compared with non-users for the same three aspects of sleep. Furthermore, there were also no important differences between sleep medicine users/non-users after 2 years of follow-up. A further finding was how none of the patients in either group, reported a worsening of sleep disturbance over the two year follow-up period.
Commenting on these results, the authors noted that over the longer term, no sleep medicines were associated with a reduction in the three main aspects of sleep disturbance compared with those who did not use such treatments. They concluded that while sleep medicines are often used off-license, over longer periods of time, the results of the study demonstrate little benefit from continued use.
Soloman DH et al. Prescription medication for sleep disturbances among midlife women during 2 years of follow-up: a SWAN retrospective cohort study. BMJ Open 2021