THE PCCA BLOG

COVID-19 & Vertigo Could Betahistine Be A Good Option?

Tue, 12 Sep 2023 16:13:07 GMT

by Deborah H. Clark, RPh, FACVP, PCCA Clinical Compounding Pharmacist

Several post infection complications have been linked with SARS-CoV-2 (COVID-19) since the beginning of the 2020 pandemic. In addition to known effects on the respiratory-system, other complications can manifest in other organ systems such as the cardiovascular, gastrointestinal and neurologic systems post COVID-19 infection.¹

Vertigo

Neurologic manifestations were widely reported and include anosmia (loss of smell), encephalopathy, encephalitis, headaches, vertigo, dizziness, Guillain-Barré syndrome, meningitis and stroke. Authors of a case study discussing the onset of vertigo in a post-COVID-19 patient defined vertigo “as a false sense of movement brought by the asymmetry in the vestibular system due to damage to the labyrinth, vestibular nerve, or central vestibular system of the brainstem or the cerebellum. Depending on the location of the pathology, it is classified as peripheral vertigo (vestibular components) or central vertigo (brain).”²

What Studies Indicate

There are several studies that examined the role of viral infections in vertigo pathogenesis. Viruses that were studied included Epstein-Barr, cytomegalovirus, rubella, adenoviruses, influenza A & B and herpes simplex. Many of the studies propose direct vestibular nerve infection as a possible mechanism and potential cause of vestibular neuritis.³ A novel link between COVID-19 and newly diagnosed tinnitus, vertigo, hearing loss and otalgia was reported; however, this link has not been fully elucidated and requires further study.⁴

Nevertheless, some studies reported an association between recent COVID-19 infection and newly diagnosed vestibular neuritis. Vestibular neuritis is a benign, self-limiting condition normally presenting with vertigo, nausea, vomiting and gait abnormality. It is thought to be due to viral or post-viral inflammation of the vestibular component of the eighth cranial nerve.² Patients who developed acute vertigo symptoms post-COVID 19 infection reported symptoms that lasted varying periods after their COVID recovery.

Case Studies – How is this Managed?

In addition to previously mentioned studies, there have been several case reports of patients entering the emergency room complaining of new onset vertigo associated with previous SARS-CoV-2 infection, with or without nausea and vomiting.1-3 These patients did not have any previous history of ear disease. Most of these patients were managed with either anti-vertigo agents, antihistamines, IV fluids or anti-nausea agents.

In one case, a 64-year-old patient reported to the emergency department with acute vertigo and without nausea and vomiting. The patient had a 9-day history of fever, cough, runny nose, dyspnea, myalgia and fatigue. After the patient was stabilized and several diagnostic tests performed, it was determined the patient had no neurologic or auditory disorders. The patient also reported contact with a confirmed COVID-19 patient who lived nearby. From the patient’s history of symptoms and lab confirmation, it was determined the patient was infected with SARS-CoV-2, which the practitioner determined to be the cause of vertigo. The physician prescribed betahistine 24mg daily as anti-vertigo medication. The patient was also prescribed other medications to treat COVID-19. The patient returned one month after recovering from COVID-19, reporting improvement of vertigo but not complete resolution. The physician continued betahistine therapy for a total of three months; vertigo resolved a month and a half after COVID-19 recovery.¹

Another study discussed a patient who reported to the ER with vertigo, nausea and vomiting lasting for three hours. As with the previous case, the patient had a history of COVID-19 infection. The patient was tested for neurological and auditory deficits and none were found. The patient was treated with ondansetron and IV fluids to control nausea and vomiting. The patient’s vertigo was managed with betahistine 16mg and an antihistamine. The patient subsequently reported complete resolution of symptoms within seven days.²

Betahistine Dihydrochloride

Betahistine dihydrochloride is a structural analog of histamine, a weak agonist of H1 receptors and antagonist of H3 receptors. It is approved for use in the treatment of Ménière’s disease and symptoms of vertigo in more than 115 countries.

In animal models of vestibular dysfunction, betahistine was observed to improve vestibular compensation by increasing blood flow in the vestibulocochlear region and decreasing the excitatory response in vestibular cells by blocking the H3 receptor cells locally. Several clinical trials have shown that betahistine improved vertigo-related symptoms — including nausea and vomiting — and effectively reduced the frequency and severity of vertigo.⁵

Betahistine dihydrochloride is not commercially manufactured in the United States. Therefore, it must be compounded for patients. Compounding pharmacists may formulate this API in a capsule to meet a patient’s need. For example, PCCA Formula #10963 – Betahistine Dihydrochloride 16mg Capsules Size #1 (LoxOral®) — is an example of a formula that may be used to help patients with COVID-19-related vertigo.

Members with clinical services access may contact our Clinical Services team to discuss compounding betahistine for COVID-19 and other compounding-related concerns.

References

Motawea, K.R., Monib, F.A. (2022) New Onset Vertigo After COVID-19 Infection. A Case Report. Indian J Otolaryngol Head Neck Surg 74 (Suppl 2), 3009–3011. Accessed September 2023 at https://doi.org/10.1007/s12070-021-02715-5
Devaragudi, S., Mohit, G. (2023) Vertigo in the Setting of COVID-19 Infection: A Case Report. Cureus vol. 15,2 e34708. Accessed September 2023 at doi:10.7759/cureus.34708
Beukes, E., Ulep, A.J., Eubank, T., et al. (2021) The Impact of COVID-19 and the Pandemic on Tinnitus: A Systematic Review. J. Clin. Med. 10, 2763. Accessed September 2023 at https://doi.org/10.3390/jcm10132763
Maharaj, S., Bello Alvarez, M., Mungul, S., et al. (2020) Otologic dysfunction in patients with COVID-19: A systematic review. Laryngoscope investigative otolaryngology vol. 5,6 1192-1196. 17. Accessed September 2023 at https://pubmed.ncbi.nlm.nih.gov/33365394/
Parfenov, V. A., Golyk, V.A., Matsnev, E.I., et al. (2017) Effectiveness of betahistine (48 mg/day) in patients with vestibular vertigo during routine practice: The VIRTUOSO study. PloS one V 12,3 e0174114. Accessed September 2023 at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174114

Glycopyrrolate Lollipops for Adults and Topical Fluoxetine for Cats: New Case Studies

Wed, 26 Jan 2022 19:11:16 GMT

By Maria Carvalho, PharmD, MRPharmS, PhD, Manager of PCCA Science

Compounding case studies describe successful patient treatments and provide scientific evidence to support the safety and efficacy of compounded medications. When case studies are published in peer-reviewed journals, pharmacists and clinicians worldwide become aware of innovative ways to treat their patients. One case study alone may improve the lives of many patients. That’s why we on the PCCA Science team work with compounders around the world to develop clinical case studies and publish them.

PCCA member Dr. Kelechi Agbi recently published two case studies featuring PCCA Sorbitol Lollipop^™ base in the International Journal of Pharmaceutical Compounding. Researchers at PCCA’s United Kingdom location also completed a case study on two veterinary patients who were successfully treated with a Lipoderm^® formula. You can find summaries of these studies below. More journal articles related to compounding will soon be published — stay tuned for more PCCA Science updates here on The PCCA Blog!

Glycopyrrolate Lollipops for Drooling in Two Adults

Study : Glycopyrrolate Sorbitol Lollipops for Drooling: Two Case Reports

Authors : Kelechi E. Agbi (Agbi’s Compounding Pharmacy, Pikesville, Maryland), Maria Carvalho and Fabiana Vieira-Banov (PCCA, Houston, Texas)

Publication : International Journal of Pharmaceutical Compounding, 25(6), 464-467

Summary : A patient with dementia and a patient with cancer both experienced persistent drooling, an issue that negatively affected their quality of life. They were both prescribed glycopyrrolate 0.5 mg sorbitol lollipops. During treatment, each of them experienced substantial decreases in the severity and frequency of drooling without any adverse effects. These two case reports demonstrate the safety and efficacy of compounded glycopyrrolate lollipops for managing excessive salivation.

For more information on the technology behind the base used in this study, visit the PCCA Sorbitol Lollipop product page on PCCA’s website.

Topically Applied Fluoxetine for Behavioral Issues in Two Cats

Study : Veterinary: Behaviour Disorders in Cats

Author : PCCA United Kingdom

Publication : PCCA Website (PCCA Document #99918)

Summary : Two cats, Charlie and Isobelle, tended to urinate and defecate in inappropriate locations around their house in the absence of their owner. These behavior issues, commonly attributed to separation-related problems, happened up to 10 times a day. Their veterinarian prescribed fluoxetine as tablets and as an oral liquid, but the cats refused both dosage forms. The veterinarian then prescribed a permeation-enhancing topical compounded medicine (fluoxetine 40 mg/Gm in Lipoderm) to be applied 0.1 mL inside the ear of the cats once daily. Following one month of treatment, the cats were no longer showing signs of emotional distress, and their behavior and wellbeing improved considerably.

For more information on the technology behind the base used in this study, visit the PCCA Lipoderm product page on our website.

The full list of PCCA case studies, and many others scientific publications, is available on the PCCA Science webpage under “ Scientific Publications .”

How We Can Help You Develop Your Own Case Study

Compounding pharmacists are on the therapeutic front lines every day and commonly hear success stories from their patients. Don’t miss the opportunity to share these stories! PCCA Science provides our members with full support in developing and writing clinical case studies. For more information on how to start a case study with us, please visit the PCCA Science webpage and click “ Initiate Case Study ” or contact us at PCCAScience@pccarx.com.

Also on The PCCA Blog: Scientific Posters Supporting the Safety and Efficacy of Compounds

Maria Carvalho, PharmD, MRPharmS, PhD, is the manager of PCCA Science. She is a certified pharmacist in Portugal and the United Kingdom with a PhD in pharmaceutical compounding from the University College of London. Maria has worked in community pharmacy, hospital pharmacy and the pharmaceutical industry in Europe and the United States. Maria has authored and co-authored many scientific publications, including the book Compounding Practices in Europe (ISBN-10:149236925X).

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.