BMJ  2004;329 (27 November), doi:10.1136/bmj.329.7477.0-f

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Steroid is effective for vestibular neuritis, valacyclovir is not

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

Synopsis Vestibular neuritis is characterised 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 two German emergency departments with vestibular neuritis diagnosed after a detailed clinical examination. They then randomised the patients (allocation concealed) to one of four groups: placebo only, methylprednisolone (MP), valacyclovir, or both. MP was initially given in a dose of 100 mg each morning for three days and then tapered slowly to 10 mg over three weeks. Valacyclovir was given as 100 mg three times a day for one week. All patients were also given 150 mg pirenzepine to reduce gastric acid secretion, and antiemetics as needed, and were admitted to the hospital for at least one day. The 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 seem to have been by intention to treat. A total of 114 patients completed the study. Six to eight patients dropped out or were lost to follow up in each group. 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. They found that treatment with MP was more effective than placebo, but valacyclovir was not. Complete or nearly complete recovery of vestibular function occurred in 8 of 30 patients in the placebo group, 10 of 27 in the valacyclovir group, 22 of 29 in the MP group, and 22 of 28 in the group receiving both drugs (27% for placebo v 76% for MP; P < 0.001, number needed to treat = 2). One patient in the MP group had a bleeding gastric ulcer and several others had mood swings or dyspepsia.

Bottom line Methylprednisolone, starting at 100 mg per day and tapering to 10 mg over three weeks, is an effective treatment for vestibular neuritis. Valacyclovir is not effective.

Level of evidence 1b (see www.infopoems.com/levels.html). Individual randomised controlled trials (with narrow confidence interval).

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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: 354-61[Abstract/Free Full Text].

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^* Patient-Oriented Evidence that Matters. See editorial ( BMJ 2002;325: 983[Free Full Text])

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