Steroid is effective for vestibular neuritis, valacyclovir is not

Journal of Family Practice, Nov, 2004 by M. Strupp, V.C. Zingler

* CLINICAL QUESTION

Which is more effective for vestibular neuritis, valacyclovir or methylprednisolone?

* BOTTOM LINE

Methylprednisolone, starting at 100 mg/d and tapering to 10 mg over 3 weeks, is an effective treatment for vestibular neuritis. Valacyclovir (Valtrex) is not effective. (Level of evidence [LOE]: 1b)

* STUDY DESIGN

Randomized controlled trial (double-blinded)

* SETTING

Concealed

* SYNOPSIS

Vestibular neuritis is characterized by sustained rotatory vertigo, positive Romberg's sign falling toward the affected ear, horizontal nystagmus toward the unaffected ear, and nausea. Because vestibular neuritis is thought to be a virally triggered inflammatory condition, it makes sense that antiviral drugs or steroids may be helpful. These authors identified 141 adults presenting to 2 German emergency departments with vestibular neuritis diagnosed after a detailed clinical examination. They then randomized the patients (allocation concealed) to 1 of 4 groups: placebo only, methylprednisolone, valacyclovir, or both.

Methylprednisolone was initially given in a dose of 100 mg each morning for 3 days and then tapered slowly to 10 mg over 3 weeks. Valacyclovir was given as 100 mg 3 times daily for 1 week. All patients were also given 150 mg pirenzepine to reduce gastric acid secretion, and also given antiemetics as needed; they were admitted to the hospital for at least 1 day. The 4 groups were similar at baseline, with a mean age between 46 and 52 years. Patients were followed-up for 12 months.

Outcomes were evaluated by assessors blinded to treatment assignment, but analysis was does not appear to have been by intention to treat. A total of 114 patients completed the study. The number of patients dropping out or lost to follow-up was similar in each group (6 to 8). The primary outcome was the degree of nystagmus provoked by caloric irrigation. This is relatively easy to quantify, and it's unfortunate that the researchers did not report any more global symptom measures.

The researchers found that treatment with methylprednisolone was more effective than placebo, but valacyclovir was not. The number of patients with complete or nearly complete recovery of vestibular function was 8 of 30 in the placebo group, 10 of 27 in the valacyclovir group, 22 of 29 in the methylprednisolone group, and 22 of 28 in the group receiving both drugs (27% for placebo vs 76% for methylprednisolone; P<.001, number needed to treat=2). One patient in the methylprednisolone group had a bleeding gastric ulcer and several others had mood swings or dyspepsia.

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Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med 2004; 351:354-361.