How Compounding Pharmacists Can Help Patients Understand the Risks and Symptoms of Vertigo
For many patients, an initial attack of dizziness can be so severe and disabling that they may immediately consult a doctor. Mike’s symptoms followed a different trajectory, however. At first he occasionally felt unsteady on his feet, but the sensation was so fleeting he didn’t worry. When unmistakable bouts of dizziness appeared, he went to the pharmacy and bought Dramamine, as recommended by his best friend, and thought it did the trick. After another vertigo attack made him fall, he ended up in the emergency room with a broken wrist. Some patients like Mike may get all the treatment needed from an OTC medication, but their health is better protected when a compounding pharmacist helps to educate them on the risks that arise when they ignore symptoms of vertigo.
The Complex Causes and Symptoms of Vertigo
While most patients sum it up their symptoms by saying they feel dizzy, this description is rather broad, as it may mean anything from slight unsteadiness and light-headedness to a floating sensation or motion intolerance. The symptoms of vertigo are more specifically defined as an illusion of movement—like the room spinning—which is caused by asymmetric input to the vestibular system. Nailing down the symptoms of vertigo makes the difference between recommending over-the-counter or compounded treatments versus referring patients to their primary care provider.
Peripheral vertigo: This type of vertigo originates in the inner ear and involves structures that control balance or the vestibular nerve. The most common type—benign paroxysmal positional vertigo (BPPV)—can often be differentiated from other types of vertigo based on duration and severity of symptoms1:
- Benign paroxysmal positional vertigo: BPPV is marked by occasional episodes of vertigo that last for a few seconds and occur when the patient changes head or body position. It often occurs out of the blue, but it’s also associated with head trauma and chronic diseases such as diabetes and osteoporosis. BPPV is a mechanical problem in which calcium carbonate crystals become dislodged and move into semicircular canals.
- Vestibular neuritis: Episodic vertigo together with nausea that lasts for days but doesn’t present with any other ear or central nervous system symptoms is a symptom of vestibular neuritis. This inner ear infection is usually viral.
- Meniere disease is often marked by vertigo that lasts for hours, as well as symptoms such as tinnitus, ear fullness and fluctuating hearing loss. In the early stage, vertigo may be severe and the patient may experience blurry vision, nausea, palpitations and anxiety.
Migraine-associated vertigo: The second most common type of vertigo is caused by migraines. About 40 percent of migraine patients experience vertigo. In fact, vertigo can be a primary symptom of migraines.2 Symptoms of vertigo for this group are quite varied and may include positional vertigo, episodic vertigo, lightheadedness and feeling constantly imbalanced.
Central vertigo: Vertigo caused by disease in the central nervous system—central vertigo—may result from tumors, trauma, infection, multiple sclerosis and stroke.3 Central vertigo secondary to ischemia usually lasts from 20 minutes up to 24 hours and is associated with diplopia, dysarthria, dysphagia and focal weakness.
Pharmaceuticals That Cause—and Those That Treat—Vertigo
Many pharmaceuticals have the potential to cause vertigo, which they usually do by triggering apoptosis or necrosis of hair cells. Classes of drugs likely to be ototoxic include antibiotics, antihypertensives, antidepressants, antipsychotics, anticonvulsants, loop diuretics and anti-inflammatory medications. Patients taking concurrent ototoxic drugs are at a higher risk, especially when a loop diuretic is combined with an aminoglycoside antibiotic.4 Patients consuming tonic water, aspirin and over-the-counter NSAIDs may also develop vertigo.
Treatment for vertigo begins with vestibular suppressants and antiemetic drugs. Mike had the right idea with meclizine, but antihistamines, anticholinergics and benzodiazepines are often prescribed. In addition to medications, physicians use physical maneuvers to move crystals in patients with BPPV and may recommend balance rehabilitation. First line treatment for Meniere’s disease includes salt restriction, diuretics, intratympanic gentamicin, and corticosteroids. Migraine-associated vertigo benefits from prophylactic medications such as calcium channel blockers, tricyclic antidepressants and beta blockers. While all classes of prophylactic medication seem to be equally effective, verapamil is often the first choice because it has the lowest risk of side effects.
Prevalence and Targeted Outreach
Vertigo originates from such diverse causes that it’s often misdiagnosed. An inner-ear specialist in Canada reported that new patients to his clinic have already spent an average of two years with other practitioners trying to get a proper diagnosis. Meanwhile, a survey taken by the Vestibular Disorders Organization found that 26 percent of 303 respondents said they were initially misdiagnosed with a condition other than a vestibular disorder.
It doesn’t take much time to reach out to this group of patients. As you offer information about vertigo and help them practice preventive medicine, you create a base of loyal customers and develop a therapeutic connection. Here are a few ideas for outreach:
- Medication Therapy Management: This is the obvious time to bring up vertigo with patients taking meds that may cause dizziness, especially if they’re elderly, have migraines or they’re diabetic.
- Diabetic patients: Make it a habit to ask diabetic patients if they ever feel dizzy.5 Having diabetes puts them at a 70 percent higher risk for vestibular disequilibrium. Vertigo may contribute to the risk of falling more than diabetic neuropathy.
- Elderly patients: The risk of vertigo—and a higher chance of falling and suffering a fracture—increases in tandem with age. In addition to talking with seniors, be sure to offer a brochure with information about vertigo to their caregivers and family members.
- Talk to parents about their children: The National Institutes of Health recently reported that 1 in 20 children have dizziness or a balance problem.6 Children aged 15 to 17 have a prevalence of 7.5 percent, while it’s 4 percent for children aged 3 to 5. Alert parents that if their child has poor coordination, frequently falls or reports feeling dizzy, they should consult their pediatrician. This is vital intervention as only 36 percent of children with vertigo are seen by a health professional.
- Balance Awareness Week: The Vestibular Disorders Association spearheads balance awareness from September 15 to 18.7 This is a good opportunity to put posters up to draw attention to vertigo and to help with patients needing medications.
Early Awareness of Vertigo Improves Outcomes
When you stop to consider that 35 percent of adults suffer from vertigo, you realize there’s a large group of patients in need of trustworthy information. And don’t forget that many of these patients self-treat using over-the-counter products, which opens the opportunity to discuss tailor-made compounded treatments. Don’t miss this chance to establish connections, build your business and promote patient health by warning about symptoms of vertigo.
Pharmaceutica North America provides high-quality bulk APIs and custom compounding kits that meet the needs of your patients suffering from vertigo. Please contact us today so we can answer any questions and work together to build and support your pharmacy.
- “Dizziness, Vertigo, and Imbalance Clinical Presentation,” August 2015, http://emedicine.medscape.com/article/2149881-clinical ↩
- “Migraine-Associated Vertigo,” March 2015, http://emedicine.medscape.com/article/884136-overview ↩
- “Central Vertigo,” November 2015, http://emedicine.medscape.com/article/794789-overview#a6 ↩
- “Ototoxicity,” 2002, http://vestibular.org/sites/default/files/page_files/Documents/Ototoxicity.pdf ↩
- “Vestibular Dysfunction: Prevalence, Impact and Need for Targeted Treatment,” June 2014, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069154/ ↩
- “More Than One in 20 US Children Have Dizziness, Balance Problems,” January 2016, https://www.sciencedaily.com/releases/2016/01/160127121203.htm ↩
- “Balance Awareness Week,” 2016, http://vestibular.org/BAW ↩