Indiana S and H Drug Side Effects 2018 - islha.org Indiana S and H Drug Sid… · Adverse Drug Reaction (ADRs) Drug Side ... B.S. SO MANY DRUGS…. ... (for COPD) 13 Categories of

3/7/2018

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Drug Side Effects on

Audiological and Vestibular Testing

Robert M. DiSogra, Au.D., FAAAAudiology Consultant

Millstone Twp., NJ

www.drbobdisogra.com

Disclosure I

There are no financial or non-

financial relationships to disclose

for this presentation

Disclosure II

Robert M. DiSogra and the

Indiana Speech-Language-

Hearing Association

endorse any of the products

mentioned in today’s program

This program is not a

complete summaryof all drugs that could

affect audiologic or

vestibular testing

Disclosure III

Dr DiSogra is receiving an

honorarium for this lecture

Disclosure IV

Learner Outcomes

1. Identify oversights your casehistory intake form that couldlead to a misdiagnosis

2. Identify auditory, vestibular,cognitive and other systems side

effects of interest to audiologists

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Learner Outcomes

3. Learn where to look for reliabledrug side effect information onthe internet

4. Learn how to report discrepantfindings

5. Improve communication between

patient and referring physicianconcerning drug side effects andtest results

6. Learn how to report an adversedug reaction to the FDA

Learner Outcomes

Adverse Drug

Reaction (ADRs)

Drug Side

Effects

Adverse Drug

Reactions

For Audiologists,

ADRs Affect 6 Areas

Auditory Balance

Cognitive Vascular

Neurological Speech

Why should Audiologists be

concerned about Adverse

Drug Reactions (ADRs)?

(other than hearing loss, tinnitus

or balance problems)

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Decreased outer hair cell function

Tinnitus Hearing loss

Dizziness Vertigo

ADRs can cause…

Perceptual changes

Sensitivity changes

(hyperacusis)

ADRs can also cause…

Fluctuations in hearing,

perception or tinnitus

due to changes in

cochlear blood flow

ADRs can also cause…

Affect

vestibular

function

and associated

balance tests

ADRs can also…

Affect visual

tracking abilities

or other visual

system functions

ADRs can also…

Mimic Hearing Loss

(hearing loss complaints with normal

audiogram, OAEs,

tymps & MEMRs)

ADRs can also…

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Result in obtaining inadequate

or “less than accurate” case

history information

Result in the selection of the

wrong diagnostics tests

ADRs can also…

Result in the wrong interpretation

of subjective tests

Result in in numerous and

unnecessary

hearing aid re-check visits

because…

ADRs can also…

“My new hearing aids just don’t

work like they used to!” 1. 30 min. - Review recent medical history (illness, new medical diagnosis, trauma, etc.)

- Otoscopy

- Listening check

- Cleaning

- Reprogram both aids

- One month recheck - N/C visit

2. 30 min. - “No improvement, Doc.”

- Send right aid to manufacturer for “bench check”

- ~ $150.00 cost to mfgr. to check an aid!

- “No problem found”

3. 30 min. - Refit right aid; send left to

mfgr.

a. ~ $150.00 cost to mfgr. to

check the aid

b. “No problem found”

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4. 30 min. - Refit left;

- Reprogram each aid;

- Rec: 1 month recheck

5. 45 min. “It’s not any better!”

- Retest hearing: no changes

- Reprogram again?

6. Patient does not come back

7. “Release of Medical Records Form”

received in your office!

What Happened?

COSTS

YOU: 2.75 hours @ $200.00/hr..... $550.00

MFGR: 2 “checks” @ $150.00….. $300.00

TOTAL = $850.00!

Recommendations

for additional

diagnostic tests can be…

Recommendations

for hearing aid

services can be…

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Academic or

occupational

recommendations can be…

Counseling

recommendations

can be…

Just How Many ADRs

“Of Interest” Are There

For Audiologists?

403

DiSogra, RM. Adverse drug reactionsand patient management. Aud Today,September 2008

403 Adverse Drug Reaction

Related Disturbances

Auditory/Hearing Related

Central Nervous System

Cognitive

Facial Nerve

LanguageDiSogra, RM Adverse Drug Reactions

and patient management, Aud Today,

September 2008



Nose, Throat and Sinus

Neurological

Speech

Vascular

Vestibular

VisualDiSogra, RM Adverse Drug Reactions

and patient management, Aud Today,

September 2008

ADR Descriptors

Reported to the FDA…

Language not

standardized

Can be very

subjective

Transient

deafness

Feeling

inebriated

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AUDITORY

Auditory disturbances Transient deafness

Ear discomfort Ear congestion

Some ADR Descriptors

AUDITORY

Roaring ears Nerve deafness

Tingling ears Tinnitus

Hearing Loss


Awareness, altered

Concentration, impaired

Confusion/Forgetfulness

Disorientation

COGNITIVE


Mental acuity, loss of

Mental clouding Mental slowness

Mental status, altered

COGNITIVE


Proprioception, loss of

Stupor Thinking abnormality

Thinking, slowed

COGNITIVE


VESTIBULAR

There are 161 ocular, optic,

visual, vascular-related, peripheral vestibular related

side effects!

Physician’s Desk Reference, 70th edition, PDR

Network, LLC, Montvale, NJ 2016


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VESTIBULAR

Dim vision Diplopia


VESTIBULAR

Dizziness Equilibrium dysfunction


VESTIBULAR

Eye movements, abnormal

Eyes, “spots” before


VESTIBULAR

Feeling, drugged - high – intoxicated

Floating feeling Frequent blinking


VESTIBULAR

Labyrinthitis

Lightheadedness Listlessness


VESTIBULAR

Meniere's syndrome Motion sickness

Movement, abnormal


Myopia

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VESTIBULAR

Ocular…discomfort

…irritation

…lesions…palsies

…pressure (hypotony)

…tension, increase


Nystagmus

VESTIBULAR

Paralysis, extra-

ocular muscles

Pupil enlargement


VESTIBULAR

Vestibular disturbances/dysfunction


Vertigo


VESTIBULAR

Vomiting

VESTIBULAR

Walking disorders

Weakness, feet / legs


VESTIBULAR

For a complete list…

Handout

[email protected]


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VASCULAR

Carotid artery

occlusion

Circulatory collapse/damage


VASCULAR

Circulatory

collapse/damage

Cerebrovascular

disorders


NEUROLOGICAL

Abnormal reflexes

CNS reactions

CNS stimulation CNS toxicity

Exhaustion/Fatigue


NEUROLOGICAL

Motor skills, impaired

Tremors

Numbness/Tingling(includes fingers/toes/limbs)


SPEECH

Speech,

incoherent/slurring

“Speech disturbances”

Stuttering


www.clinicaltrials.gov

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Clinical Studies as of 2/ 19 /18

Hearing loss 144

Tinnitus 22

Vestibular 62

Fall Risk 23

DOCUMENTATION

for

Toxic Symptoms

and

Associated

Time Frames

Your Case History

Questions

Standard Case History Questions

“What drug’s are you currently

taking and why?”

“List all your medications and

why you take them.”

“A little red pill in the morning and a white one at night”

“Just Zoloft ….for my cholesterol!”

“ I take little pills for my insides.”

“You just can’t make

this stuff up!”

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Audiologist: “What medications do

you take?”

Patient: “I have a list.”

Audiologist: “Great! May I see it?”

(Patient now fumbles though wallet)

Wait a minute –

it’s here somewhere

OK!...Here!.....

Potassium - garlic

Lecithin 1200mg

Vitamin C 500mg

Selenium 50mcg

Centrum (silver)

Ginkgo biloba

Nitroglycerin 6.5mg

Lasix (furosemide)

Plavix 75mg

Prinivil 10mg

Delta-Cort (Delacort)

Metropolol (Lopressor) 50mg

Fe-Tenic 150

Fosamax

Prednisone

Norvasc

Get to know your

pharmacist

Patient Management

Bring in ALL Medications

(don’t rely on their memory)

Detailed Patient History

Rx History - ALL Drugs!

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Night time

Day time Patient

Drug Card

Used with permission

Jane Watson, Au.D.

Carrol Green, B.S.

www.carezone.com

SO MANY DRUGS….

SO LITTLE TIME!

Is There a Side Effects

Reference for Audiologists?

( I hope he says, “Yes!” )

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Original List

Adverse Drug

Reactions

1993

750 Drugs

83 ADRs

2nd Edition

Adverse Drug

Reactions

September 2001

1500 Drugs

315 ADRs

3rd Edition

Adverse Drug

Reactions

2008

~2000 Drugs

403 ADRs Out of Print

Compliments of

ESCO

and Oaktree

Products

www.earservsecure.com/drugs

Audiology-Related Side Effects

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Auditory/Hearing Related

Central Nervous System

Cognitive

Facial Nerve

Language



Nose, Throat and Sinus

Neurological

Speech

Vascular

Vestibular

Visual

• Visual (91) 23.0%

• Vascular (60) 15.0

• Neurological (67) 17.0

• Auditory/Hearing Related (46) 11.5

• Nose, Throat and Sinus (32) 8.0

• Vestibular (32) 8.0



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• Cognitive (26) 6.5%

• Central Nervous System (13) 3.0

• Other (13) 3.0

• Speech (11) 2.7

• Facial Nerve (9) 2.5

• Language (1) 0.3



• Visual (91) 23.0%

• Vestibular (32) + 8.0

31.0%!

Almost 1/3 of ADRs can affect a

Balance Assessment



5 Categories of Drugs

That Cause HL

Aspirin Loop diuretics

NSAIDs Chemotherapy drugs

Antibiotics (AMGs)

13 Categories of Drugs That Cause

Vestibular Problems

Antibiotics (AMGs) Diuretics

Anti-hypertensives

Mucolytics (for COPD)

13 Categories of Drugs That Cause

Vestibular Problems

Anti-inflammatory

NSAIDs Anti-depressants

Cholesterol-lowering

13 Categories of Drugs That Cause Vestibular Problems

Anti-fungals Anti-malarials

Heavy metals Anti-psychotics

Parkinsonian drugs

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Internet Resources

Owner: Drugsite Trust

Auckland, NZ

Data Center: Dallas TX

Owned and Operated by WebMD

San Clemente, CA

Dizziness Incidence 0.5%

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epocrates.com Drug Manufacturers

How About A Few

Case Studies?

63 y.o. male seen in June, 2012

Attorney - private practice 25 years

Retired US Army Reserve Captain

Viet Nam veteran

Case Study #1

Medical diagnosisAnxiety and depression (2010)

Gastritis (2011)

ManagementUnder the care of a since 2010

with weekly sessions

Case Study #1 Chief Complaints:

Tinnitus (“constant ringing” AU)

Memory and word finding problems (for two years)

Confusion (at times)

Migraine headaches (daily)

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2012 Medications


CelexaAnti-depressant

2010 – present

confusion, dizziness, tinnitus, vertigo,impaired mental performance, stupor

2012 MedicationsWelbutrin

(anti-depressant)

2010 – present

confusion, auditory disturbances, aphasia,

sensory disturbances,

memory impairment, dizziness,

thinking abnormality

Xanax(anti-anxiety)

2010 – present

confusion, inappropriate behavior, tinnitus, cognitive impairment, dizziness, auditory

disturbances, memory impairment, impaired mental performance

Topamax(bi-polar disorder)

2011 – present

confusion, decreased hearing, dizziness,hyperacusis, mental performance

impairment, ear pain, language problems,

tinnitus, vertigo

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Imitrex(migraine headache relief)

2011 – present

confusion, temporal arteritis

Prilosec(gastritis)

2012

confusion, dizziness, tinnitus, vertigo

Tinnitus reported after Topamax was

increased from 200 mg to 400 mg

starting February, 2012

Audiometrics (June 2012)

WNL* from 250 - 8000 Hz

Normal middle ear function with

MEMRs present at normal SLs

Normal DPOAEs to 8000 Hz

WDS 100% at MCL (55dB HL)

UCLs 95dB HL

Topamax

Increased to 400 mg (from 200 mg) in

February 2012

Tinnitus reported immediately!

Drug/Symptom Time Lines

The report indicted the correlation

between the time line and tinnitus

(after no peripheral hearing loss was identified)…

Topamax was decreased back to

200 mg July 2012; tinnitus stopped!

Drug/Symptom Time Lines

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Case Study #2 Case Study #2

August 2012

87 y.o. male with a +10 year history of moderate SNHL bilaterally – age related

Typical communication complaints

Wearing two digital ITEs for ~ one year with much success!

V

V

V

V

V V

V

V

V

V V V

History of S/N HL

Medical History5 year history of cardiac

arrhythmia and angina

2012 Medication List

Nitrobid (9 mg) - angina (2009)

2012 Medication List

Atenolol (50 mg) BP/arhythmia

one year (d/c Procardia taken

since 2008)

Dosage was increased from 25mg to 50mg in June, 2012

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Prevacid (15mg) – Gastro-

Esophegeal Reflux Disease

(GERD) since July, 2012

Aspirin (325mg) – daily since 2000

2012 Medication List July 2012

Wife:

“Ever since his ‘Atinol’

was increased from

25mg to 50mg last month (June)

he doesn’t hear anymore!”


Atenolol(reported as “Atinol”)

No Auditory-related ADRs

Nitrobid

No Auditory-related ADRs History of S/N HLRepeat

Audiogram

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June 2012: Atenolol -“Atinol”

increased (25 mg to 50 mg)

July: added Prevacid (GERD)

August: “He just doesn’t hear…”

complaint reported by wife

Time Line – Symptom Correlation

What’s your

clinical impression?

Would you think to look up

any ADRs for PREVACID??

CVA circulatory failure confusiondeafness dizziness nausea

otitis media speech disturbances

thinking abnormality tinnitusvisual field defects vomiting

The Problem

Patient’s wife:

- Mispronounced drug’s name(“Atinol” for “Atenolol”)

The Problem

Patient’s wife:

- Blamed the wrong drug for the hearing loss complaint

- Confused time line

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PCP: Prevacid could not be d/c’d

Communication strategies were

reviewed in detail again

Re-checks every

3 months

Audiology Alert!

Your patient could report that they

are taking

Drug “A”

when they are actually taking

Drug “B”!

Patanol Opthalmic drops for pink eye

Paramol Acetaminophen

Platinol Head /Neck cancer Ototoxic!

Zoloft

anti-depressant

Zocor

lowers cholesterol

UPPER

and

lower case

lettering

on labels

FDA Recommends Case Study #3

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Case Study #3 Case Study #3

- 46 y.o. female attorney

- 2 year history of

anxiety and depression after

being let go from

a large law firm

Case Study #3

- Now working P/T in

public defender’s

office

- Seeing a psychologist weekly

Case Study #3

- A & D worsening

- Referred to psychiatrist by

psychologist

2017 Medication

Celexa 40 mg daily(anti-depressant)

Case Study #3

- Vertigo reported

several days

after Rx

- Referred to ENT by psychiatrist

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ENT and Audiological

Testing WNL*Video Nystag-

moGraphy (caloric)

Vestibular Evoked

Myogenic Potentials

(VEMP)

Balance Assessment

Dynamic Visual

Acuity Test (DVAT)

Rotary Chair

Computerized

Dynamic

Posturography

Balance AssessmentNo Evidence of

Peripheral Vestibular Dysfunction

No Evidence of

Peripheral Hearing Loss

Normal ENT Exam


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Case Study #3

Recommendations

1.Decrease Celexa to 20 mg and monitor vestibular symptoms

2. D/C Celexa if symptoms persist

3. Consider alternate Rx w/o similar

side effects

Informing Your Patient

Keep In Mind…

Safety and Efficacy

have already been

established and

accepted by the

FDA

Keep In Mind…

ADR incidence may be extremely low

(1 in 500, <1%, etc.)

“…used for guidance…”

Use Caution

When

Identifying

Vascular ADRs

Don’t Scare

Your Patient!

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“Did you know

that your

medication could

cause you to have

heart attack?”

NO!! Reporting Your Findings

Test results show no evidence of any

_______ however, the patient started taking

_______ on ( date ). This medication has_______ as a reported side effect. [site your

source]

Reporting Your Findings

In reviewing the symptom time line with the

start of this medication, it would appear

that the patient's _______ complaint may berelated to this medication.

Get to know

your Pharmacist

Reporting an Adverse

Event to the FDA

www.fda.gov/medwatch

1.800.FDA.1088

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Contact the Drug

Manufacturer Directly

CONTACT US

Program Takeaways

Thorough case history Q’s re: Rx

Have pt bring in list of their meds

Keep Pharmacist phone # handy

Program Takeaways

Establish time lines

There are reliable internetresources for drug info

OK to contact thedrug manufacturer

Program Takeaways

Don’t alarm your patients with any

vascular related side effect

Report test discrepancies relative

to drug time lines and

possible side effects

Program Takeaways

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“Dr. Bob – May I be excused – my brain is full!”

I’ll stop talking now and

you can ask questions!

Thank you!

www.drbobdisogra.com

Documents

Indiana S and H Drug Side Effects 2018 - islha.org Indiana S and H Drug Sid… · Adverse Drug Reaction (ADRs) Drug Side ... B.S. SO MANY DRUGS…. ... (for COPD) 13 Categories of