Vertigo Management – Mapping prevalence and treatment. Understanding once a day preparation usage and place in therapy.

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7.      What is the usual line of treatment?

Total Respondents = 165 (multiple responses)

Line of Treatment

Responses

% of Responses

Lifestyle modification

2

0.88

Pharmacological

120

53.12

Manoeuvres only

3

1.33

Pharmacological and Manoeuvres

101

44.69

Table 98: Responses for usual line of treatment in Vertigo management

Interpretation:
·         53.12% Sampled doctors majorly resort to Pharmacological therapy for treating Vertigo.
·         Pharmacological and Manoeuvres is preferred line of treatment amongst 44.69% Sampled doctors for effective Vertigo management.
·         0.88% doctors suggest a Lifestyle modification & 1.33% doctors suggest only manoeuvres in Vertigo management.
·         Pharmacological % Manoeuvres is the most preferred line of treatment amongst 70.58% Neurologists & 49.28% E.N.T Doctors for effective Vertigo management.
·         Pharmacological therapy is the most preferred line of treatment amongst 68.92% Consulting Physicians, 68.18% Cardiologists & 70% Diabetologists for treating Vertigo.

8.      In pharmacological treatment what is your drug of choice?

Total Respondents = 165 (multiple responses)

Molecule

Responses

% of Responses

Betahistine

161

80.5

Cinnarizine

13

6.5

Dimenhydrinate

9

4.5

Combination

14

7

Any other

3

1.5

Table 99: Responses for molecule management in Vertigo management pharmacologically

Interpretation:
·         Betahistine) is the most preferred drug of choice for treating vertigo amongst 80.5% sampled doctors.
·         4.5 % Sampled doctors prescribed Dimenhydrinate and 7% Sampled doctors prefer to use a combination of drugs (Betahistine with Dimenhydrinate / Cinnarizine) to treating Vertigo.
·         6.5% doctors prescribe Cinnarizine while the rest 1.5% prescribes other medication (diuretics etc).

9.      May I know your usual treatment approach?

 

8 mg

16mg

24mg

24mg C.R

48 mg C.R

OD

--

--

--

11

1

BID

5

26

23

--

--

TID

67

15

13

--

--

Table 100: Chart showing the type of Betahistine dose prescribed for treating Vertigo

Total Respondents = 165

Interpretation:
•    40.61% of the Sampled doctors prefer to give 8mg TID dose of Betahistine to patients to treat vertigo.
•    7.88% of the Sampled doctors prescribe 24mg BID dosage, while 15.76% of them prefer 16mg BID o& 13.94% doctors prefer 24 mg TID dose, for pharmacological therapy with Betahistine for Vertigo.
•    Only 6.67% of Sampled doctors prescribes 24mg C.R once a day formulation (Betahistine O.D) for treatment in of Vertigo.
•    Also, 0.61% Sampled doctors prescribe 16mg TID of Betahistine to their patients.  
•    Betahistine is the most preferred drug of choice for treating vertigo amongst 86.96% Neurologists, 83.58% Consulting Physicians, 100% Cardiologists, 61.11% E.N.T Doctors & 90.9% Diabetologists.
•    42.5% of the Neurologists, 33.33% of the Consulting Physicians, 55 % of the Cardiologists, 48.57% of the E.N.T Doctors & 30% of the Diabetologists prefer to give 8mg TID dose of Betahistine to patients to treat vertigo.

Duration:
Total Respondents = 165

Duration

Responses

 

Table 101: Responses for duration of pharmacological therapy for Vertigo

% of responses

1-2 weeks

118

71.52

3-4 weeks

43

26.06

4-8 weeks

4

2.42

Interpretation:

·                     1-2 weeks is the most preferred duration of therapy with Betahistine amongst 71.52% Sampled doctors.
·                     26.06% Sampled doctors opted for 3-4 weeks of therapy with Betahistine, while 2.42% preferred 4-8 weeks.
·                     1-2 weeks is the most preferred duration of therapy with Betahistine amongst 75% Neurologists, 73.33% Consulting Physicians, 65% Cardiologists, 62.86% E.N.T Doctors & 90% Diabetologists.

10.  Do you titrate dosage?

Total Respondents = 165

Response to question

Responses

% of Responses

Yes

149

90.3

No

16

9.7

Table 102: Responses for dosage titration in treating Vertigo

Interpretation:
·         90.3% of the Sampled doctors were found to titrate the dosage in Vertigo treatment.
·         With the usual approach being tapering down the dosage in patients where symptoms are relieved and do not recur, and then putting it off. But in some recurrent cases of vertigo the dosage was increased.
·         Where as 9.7% of the Sampled doctors did not titrate the dosage.
·         90% of the Neurologists, 95% of the Consulting Physicians, 80% of the Cardiologists, 88.57% of the E.N.T Doctors & 90% of the Diabetologists were found to titrate the dosage in Vertigo treatment.

11.  Doctor, are you aware of once a day Betahistine preparation?

Total Respondents = 165

Response to question

Responses

% of Responses

Yes

157

95.15

No

8

4.85

Table 103: Responses for Betahistine O.D awareness

Interpretation:
·         Majority (95.15%) of the Sampled doctors were found to be aware of Betahistine once a day preparation. Only 4.85% Sampled doctors were still unaware of Betahistine O.D formulation.
·         95% of the Neurologists, 98.33% of the Consulting Physicians, 80% of the Cardiologists, 100% of E.N.T doctors & 90% of the Diabetologists were found to be aware of Betahistine once a day preparation.

12.  If Yes, have you used?

Total Respondents = 165

Response to question

Responses

% of Responses

Yes

75

45.45

No

90

54.55

Table 104: Responses for Betahistine O.D usage

Interpretation:
·         45.45% of the sampled doctors, were found to use Betahistine O.D formulation.
·         54.55% of the sampled doctors did not use Betahistine O.D formulation, they reportedly used the conventional doses.
·         55% of the sampled Neurologists, were found to use Betahistine O.D formulation
·         53.33% of the Consulting Physicians, 70% of the Cardiologists, 57.14% of the E.N.T Doctors & 60% of the Diabetologists did not use Betahistine O.D formulation, they reportedly used the conventional doses.

13.  If answer to Q11 is Yes, what is preferred strength & duration?

Total Respondents = 75 (out of 165 Sampled doctors)

Strength

Duration

Responses

% of Responses

Overall %

24 mg

1 week

29

54.71

70.67

2 weeks

23

43.33

4 weeks

1

1.89

 

48 mg

1 week

8

36.36

29.33

2 weeks

10

27.78

4 weeks

4

11.11

Table 105: Responses for preferred strength of Betahistine O.D usage

Interpretation:
·         Amongst all Sampled doctors those who use Betahistine once a day preparation, 70.67% mostly prescribe 24mg C.R, while 29.33% use 48mg C.R formulation.
·         The duration for which 24mg C.R is prescribed the most is 1 week by 54.71% Sampled doctors, followed by 2 weeks amongst 43.33% Sampled doctors.
·         36.36% Sampled doctors use 48mg C.R for 2 weeks.
·         27.78% Sampled doctors use 48mg C.R for 4 weeks.
·         1.89% doctors prescribed 24mg C.R for 4 weeks and 11.11% prescribed 48mg C.R for 4 weeks

·         Amongst the sample set, the O.D usage is as follows:
a.      Neurologists those who use Betahistine once a day preparation, 77.27% mostly prescribe 24mg C.R, while 22.73% use 48mg C.R formulation
b.      Consulting Physicians those who use Betahistine once a day preparation, mostly (60.71%) prescribe 24mg C.R, while 39.29% use 48mg C.R formulation.
c.       Cardiologists those who use Betahistine once a day preparation, 66.67% mostly prescribe 24mg C.R, while 33.33% use 48mg C.R formulation.
d.      E.N.T Doctors those who use Betahistine once a day preparation, 73.33% mostly prescribe 24mg C.R, while 26.67% use 48mg C.R formulation.
e.       Diabetologists those who use Betahistine once a day preparation, 100%  prescribe 24mg C.R, while none  use 48mg C.R formulation.

·         Amongst the sample set the duration of O.D usage is as follows:
a.      The duration for which 24mg C.R is prescribed the most is 1 week by 50% Neurologists, followed by 2 weeks amongst 22.73% Neurologists.
b.      32.14% of Consulting Physicians prescribe 24mg C.R for 1 week, followed by 32.14% of Consulting Physicians for 2 weeks
c.       The duration for which 24mg C.R is prescribed the most, is equally by 33.33% Cardiologists for 1 week and 2 weeks respectively.
d.      The duration for which 24mg C.R is prescribed the most is 1 week by 53.33% E.N.T Doctors, followed by 2 weeks amongst 20% E.N.T Doctors
e.       The duration for which 24mg C.R is prescribed the most is 2 weeks by 100% Diabetologists

14.  If used, how do you use the OD formulation?

Total Respondents = 165

Response to question

Responses

% of Responses

Start with OD

100

60.61

Only Maintenance with OD

65

39.39

Table 106: Responses for preferred use of once a day formulation

Interpretation:
·         60.61% of the sampled doctors prefer to use O.D formulation as a start up dose, while the rest (39.39%) preferred to use it as a maintenance dose only.
·         67.5% of the Neurologists, 53.33% of the Consulting Physicians, 60% of the Cardiologists, 62.86% E.N.T doctors & 70% of the Diabetologists prefer to use O.D formulation as a start up dose.

15.   Is the usage of OD preparation indication specific?

Total Respondents = 165

Response to question

Responses

% of Responses

Yes

16

9.7

No

149

90.3

Table 107: Responses for preferred use of once a day formulation

Interpretation:
·         Majority (90.3%) of the Sampled doctors do not use O.D formulation particularly specific to any indication.
·         Only 9.7% of Sampled doctors use it specific to any particular condition.
·         82.5% of the Neurologists, 96.67% of the Consulting Physicians, 95% of the Cardiologists, 85.71% of the E.N.T doctors & 90% of the Diabetologists  do not use O.D formulation particularly specific to any indication

16.  If yes, which is the indication and any specific reasons?

9.7% of the Sampled doctors use O.D formulation in Acute cases of vertigo. They also prefer to use it in patients with severe symptoms.

17.  Do you also use two anti-vertigo molecules like morning/evening dose?

Total Respondents = 165

Response to question

Responses

% of Responses

Yes

26

15.76

No

139

84.24

Table 108: Responses for usage of two Anti-vertigo molecules

Interpretation:
·         84.24% of the Sampled doctors do not use two Anti-Vertigo molecules together.
·         Only 15.76% of the Sampled doctors use two Anti-vertigo molecules together as a morning-evening dose
·         90% of the Neurologists, 78.33% of the Consulting Physicians, 90% of the Cardiologists, 85.71% of the E.N.T Doctors & 80% of the Diabetologists do not use two Anti-Vertigo molecules together.

If Yes, your usual approach

Sometimes Betahistine is prescribed with Dimenhydrinate or Cinnarizine.

18.  Do you think, combination of Betahistine with Dimenhydrinate is required? If yes, for which indication and condition is it useful?

Total Respondents = 165

Response

Number of Responses

% of response

Yes

74

44.85

No

9

5.45

Maybe

12

7.27

Not tried

70

42.42

Table 109: Responses for usage of combination of Betahistine with Dimenhydrinate

Interpretation:
·         42.42% of the sampled doctors have not tried this combination, but 44.85% said it to be a potent and viable combination.
·         They were further aided by 7.27% of doctors who felt it maybe a fruitful combination.
·         5.45% of sampled doctors feel that this would not serve to be a good combination.
·         37.5% Neurologists, 45% of Consulting Physicians, 45% Cardiologists, 54.29% E.N.T doctors and 40% Diabetologists said it to be a potent and viable combination

KEY FINDINGS
·               The incidence of patients who seek anti-vertigo medications was found to be 10-15% of the total number of patients that a doctor sees in a week.
·               The percentage of female patients who seek anti-vertigo medications were found to be the majority amongst doctors in the ratio of 40:60 (Male : Female)
·               The incidence of the patients were found to be predominant in the 40-50 years category amongst the doctors.
·               The study revealed that majority of patients reported to the doctors had secondary to some pre-existing ailment.
·               Diabetes Mellitus, Hypertension, Cervical Spondylosis, Cardiac problems, & Thyroid  were the prime secondary to some pre-existing ailment. Even cases of dehydration related vertigo during summer months were reported to doctors.
·               BPPV was found out to be the most common cause. Following to it were Labyrinthitis and Vestibular Neuritis as most popular causes. Meniere’s disease and Migraine were the least of the causative factors. Vertebro-Basilar Ischemia and Syncope were also reported as the least effective cause along with Stroke and Cervical Spondylosis.
·               Pharmacological and Manoeuvres is the most preferred line of treatment amongst ENT and Neurology doctors. The doctors of other speciality preferred Pharmacological treatment.
·               Betahistine is the most preferred drug of choice amongst the doctors.
·               Combination of Cinnarizine and Dimenhydrinate with Betahistine was also reported in few cases.   
·               The usual strength of Betahistine varies depends upon the severity condition. It was found to range in between 8mg-16mg. The average duration of drug administration was around 3-4 weeks, though in some cases 1-2 weeks was also reported.
·               Majority of the doctors were found to prescribe 8mg Betahistine TID for 1-2 weeks or 16mg Betahistine BID for 1 week.
·               Some doctors (majorly Neurologists) even prescribed the OD formulation on grounds of higher patient compliance. Though, a higher number of doctors reported that TID / BID resulted in higher degree of success in therapy.
·               Inability to titrate the dosage and patient’s psychology in taking medicine were the distinct disadvantages of OD formulation.
·               The majority of the doctors were found to titrate the dosage.
·               Majority of the doctors taper the dose down to 8mg (BID) and then put it off. In certain severe cases it was found that the doctors even tapered up the dosage to 16mg BID.
·               Majority of the doctors are aware of once a day Betahistine preparation, which is indicative of good promotion on behalf of the company.
·               A good number of the doctors (Neurologists, Cardiologists, C.P) used Betahistine OD.
·               Those doctors who are aware of Betahistine OD and use it, basically administer 24mg for 1-2 weeks. They even prescribe 48mg for 3-4 weeks. No doctor responded for 32mg OD preparation.
·               Some doctors, complained of unavailability and sighted grounds of improper promotion. Rest of the doctors who do not use Betahistine OD said they were not used to it and never tried it.
·               Majority of the doctors prefer to use Betahistine OD preparation as start up dose, while the rest use it to maintain the patients on it.
·               The use of Betahistine OD preparation was not indication specific amongst the majority of the doctors. Though few used it for acute cases.
·               Majority of the doctors do not use two anti-vertigo molecules.
·               A fair share of the doctors felt that it is a potential and a viable combination. They also suggested it should be a good approach to treat Central and Peripheral vertigo. Some used Stemityl 5mg to overcome emetic problems

S.W.O.T Analysis for Betahistine O.D formulation

RECOMMENDATIONS
If the company was to modify its existing Betahistine OD and its position:
•    Since OD preparation usage is not majorly indication specific, doctors could be made aware to use Betahistine OD as a start-up dose.
•    Doctors who prescribe TID/BID doses should be made aware of OD formulation.
•    Discussions regarding, that success rate do not vary with OD doses could be carried out.
•    A possible combination with Dimenhydrinate could be formulated (as 45% of customers thought of it as a potent customer)
•    Since majority of the patients were 40-50 years old, OD dose with low side effects (gastric problems) could be introduced or lower strength OD formulation could also be introduced.
•    Diabetes is the most common secondary to pre-existing ailment along with hypertension and cardiac problems. Doctors of these specialities could be illustrated to co-prescribe Betahistine O.D formulation (with higher patient compliance) to prevent attacks of vertigo.
•    Orthopaedic doctors could also be thought of as a potent customer as Spondylosis is a popular cause of Vertigo.
•    Since incidence of female patients requiring anti-vertigo medications is higher than male patients, Gynaecological doctors & Endocrinologists could be added into the customer base.
•    Majority of the doctors are aware of Betahistine OD preparation, but still they are hesitant to use it. It is due to their preference to the time tested conventional doses. Discussions pertaining to:
i)    patient compliance,
ii)    changing the customer’s perception: that there is no significant difference in OD and conventional doses (so that they can instil the confidence in the end consumers to change their psychology),
iii)    freedom from dosage titration and
iv)    elimination of problems pertaining to dosage accumulation could be carried out.  
•    Effective marketing through journals, internet etc could be mediated to focus on advantages (patient compliance) of OD preparation over conventional doses
•    Betahistine (82.65 crores)  contributes 27.73% of the entire Somatologicals market share (297.59 crores), widened window of growth.
•    The market potential for Betahistine O.D formulation is good. The product is in the introductory phase. To achieve a faster growth a competitive pricing strategy could be framed.

REFERENCES
Books referred:
1.    Essentials of Medical Pharmacology; K.D. Tripathi, 5th Edition, 2003, Jaypee Brothers Medical Publishers (P) Ltd.
2.    Principles of Anatomy & Physiology; Gerard J. Tortora, Bryan Derrickson, 13th Edition, 2011, Volume – 1 & 2, John Wiley & Sons (Asia) Pte Ltd.
3.    Goodman & Gilman’s The Pharmacological Basis of Therapeutics; Laurence L. Brunton, Bruce A. Chabner, Bjorn C. Knollmann, 12th Edition, 2011, McGraw Hill Medical Publishers
4.    Harrison’s Principles of Internal Medicine; Anthony S. Fauci, Eugene Braunwald, Dennis L. Kasper, Stephen L. Hauser, 17th Edition, 2008 Volume 1,  The McGraw Hill Companies Inc.
5.    Drug Facts and Comparisons; Wolters Kluwer Health, 2008 Edition
6.    Journals from W.H.O repository

Online / e- References:
1.    Meniere’ Disease: Marc A Thorp, Department of Otolaryngology, Corner Brook, Newfoundland, Canada
2.    Betahistine in the treatment of vertiginous syndromes: a meta-analysis C. DELLA PEPA, G. GUIDETTI1, M. EANDI Department of Anatomy, Pharmacology and Forensic Medicine, University of Turin; 1 Service of Audio-Vestibology and Vestibular Rehabilitation, A.S.L. (Local Health Service) of Modena, Modena, Italy
3.    medibolism.com/medication/betahistine-hydrochloride/
4.    High-dosage Betahistine dihydrochloride between 288 and 480 mg/day in patients with severe Menie`re’s disease: a case series Franziska Lezius • Christine Adrion • Ulrich Mansmann • Klaus Jahn • Michael Strupp
Received: 20 February 2011 / Accepted: 11 May 2011 / Published online: 29 May 2011_ Springer-Verlag 2011
5.    Review Article: Inner Ear Disease and Benign Paroxysmal Positional Vertigo: A Critical Review of Incidence, Clinical Characteristics and Management
M. Riga,1 A. Bibas,2 J. Xenellis,2 and S. Korres2
1ENT Department, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, 68100 Alexandroupolis, Greece
2ENT Department, Hippokrateion General Hospital of Athens and National University of Athens, 11527 Athens, Greece
6.    ncbi.nlm.nih.govpmcarticlesPMC2640000tool=pubmed
7.    ncbi.nlm.nih.govpmcarticlesPMC2655085
8.    ncbi.nlm.nih.govpmcarticlesPMC2866460tool=pmcentrez
9.    ncbi.nlm.nih.govpmcarticlesPMC3201005tool=pmcentrez
10.    Medical Management of Vestibular Disorders and Vestibular Rehabilitation by Kevin Katzenmeyer & Jeffrey Vrabec
11.    betterhealth.vic.gov.au\emergencydepartmentfactsheet\vertigo
12.    Vertigo Can Be Treated Easily And Quickly, Science Daily (May 26, 2008)
13.    Medical treatment for vertigo, C. Desloovere, Department of Ear, Nose and Throat disease, University Hospital, Catholic University of Leuven, Belgium

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