#ototoxicity

[bethiniancorpuscle]

Common ototoxic medications

"FAV Q&A"

Furosemide (and other loop diuretics) Aminoglycosides Vancomycin Quinine Aspirin

[er-cryptid]

Drugs Causing Ototoxicity

Loop Diuretics

Furosemide

Bumetanide

Ethacrynic Acid

Antibiotics

Aminoglycosides

Macrolides

Vancomycin

Minocycline

NSAIDs

Aspirin

Indomethacin

Ibuprofen

Phenylbutazone

PDES Inhibitors

Sildenafil

Tadalafil

Vardenafil

Platinum Agents

Cisplatin

Carboplatin

Other

Quinine

Patreon | Ko-fi

[drrajbhayani]

Ototoxic Medications: Drugs That Can Harm Your Hearing

By Dr. Raj Bhayani, ENT Specialist

ENT doctor reviewing ototoxic medications hearing loss risk with patient

Most people think of medication side effects in terms of stomach upset, drowsiness, or the occasional rash. Fewer people realize that some medications, prescribed for genuinely serious conditions, carry a real risk of damaging hearing or balance. This is known as ototoxicity, and understanding which ototoxic medications carry this risk is an important, often overlooked part of protecting your hearing.

As an ENT, I don't want this information to cause unnecessary alarm. Many of these medications are essential, sometimes lifesaving, and the benefit clearly outweighs the risk in the situations where they're prescribed. But being informed helps you recognize warning signs early and have an educated conversation with your prescribing doctor when it matters.

In this guide, I'll explain what ototoxicity is, the common culprit medications, the signs of trouble to watch for, who's at the highest risk, and how to protect your hearing.

What Ototoxicity Is

Ototoxicity refers to damage to the inner ear, affecting hearing, balance, or both, caused by exposure to certain medications or chemicals. This damage typically occurs at the level of the delicate hair cells in the inner ear, the same structures responsible for converting sound into signals the brain can interpret and for helping maintain balance.

Depending on the specific medication, dose, and duration of use, ototoxic effects can range from temporary and reversible to permanent. Some medications primarily affect hearing, some primarily affect balance, and others can affect both.

Why This Matters Even Though It's Uncommon

While ototoxicity isn't the most common side effect associated with these medications, its potential to cause permanent hearing or balance damage means it deserves genuine attention, particularly for medications used in higher doses, for extended periods, or in patients with additional risk factors.

Common Culprit Medications

Several categories of medications are well-recognized for their potential to cause hearing damage or balance issues.

Aminoglycoside Antibiotics

This class of antibiotics, used for certain serious bacterial infections, is one of the most well-documented causes of ototoxicity. The risk increases with higher doses, longer treatment duration, and combined use with other ototoxic medications.

Certain Chemotherapy Drugs

Some chemotherapy medications, particularly a class called platinum-based agents, are known to carry a meaningful risk of causing hearing loss, sometimes significant, which is an important consideration in cancer treatment planning and monitoring.

Loop Diuretics

Certain diuretics, typically used at high doses or in patients with kidney issues affecting how the medication is processed, have been associated with hearing changes, which are sometimes reversible.

High-Dose Aspirin and Certain NSAIDs

Very high doses of aspirin, well above typical over-the-counter use, have been linked to medication tinnitus and temporary hearing changes, which are generally reversible once the dose is reduced or the medication is stopped.

Quinine and Related Medications

Quinine, historically used for malaria and sometimes for leg cramps, has a recognized association with tinnitus and hearing changes, particularly at higher doses.

Signs of Trouble

Recognizing early warning signs while taking a potentially ototoxic medication is one of the most important steps in preventing permanent damage.

Hearing-Related Signs

New or worsening tinnitus (ringing, buzzing, or hissing in the ears)

Difficulty understanding speech, particularly in noisy environments

A sense of muffled or reduced hearing

Hearing changes that seem to correspond with starting or increasing a specific medication

Balance-Related Signs

New dizziness or unsteadiness

A sense of imbalance, particularly when walking in the dark or on uneven surfaces

Vertigo or a spinning sensation

Why Reporting Symptoms Promptly Matters

For many ototoxic medications, catching symptoms early and adjusting or stopping the medication, when medically appropriate, gives the best chance of preventing permanent damage. Waiting to mention symptoms can allow potentially reversible changes to become permanent.

Who's Most at Risk

Not everyone taking a potentially ototoxic medication will experience hearing or balance problems. Certain factors increase the likelihood of ototoxic effects.

Key Risk Factors

Higher doses or longer treatment duration

Kidney impairment, which can affect how quickly a medication is cleared from the body, prolonging exposure

Combined use of multiple ototoxic medications at the same time

Pre-existing hearing loss, which may make the inner ear more vulnerable to further damage

Older age, which is often associated with reduced kidney function and pre-existing hearing changes

Special Considerations in Certain Treatments

For treatments like specific antibiotics or chemotherapy where ototoxic risk is well established, hearing monitoring is often built directly into the treatment protocol, allowing doctors to catch early changes before they become severe.

Protecting Your Hearing

If you're prescribed a medication with known ototoxic potential, there are meaningful steps you can take to protect your hearing.

Practical Steps

Ask your prescribing doctor directly whether a medication carries ototoxic risk, particularly for higher-dose or longer-term treatments

Request a baseline hearing test before starting a medication with significant ototoxic risk, when appropriate for your situation

Report any new hearing, tinnitus, or balance symptoms to your doctor promptly, rather than waiting to see if they resolve on their own

Ask about monitoring hearing tests during treatment if you're on a medication with well-established ototoxic risk

Working With Your Care Team

Because these medications are often prescribed for serious conditions, decisions about adjusting or stopping them need to be made carefully, weighing the treatment benefit against the hearing risk. This is a conversation best had directly with your prescribing doctor, sometimes alongside an ENT.

Baseline hearing test monitoring for ototoxic medication treatment

Conclusion

Ototoxicity is a real but often overlooked risk associated with certain important medications, ranging from specific antibiotics to some chemotherapy drugs and high-dose aspirin. In most cases, these medications are prescribed because their benefit clearly outweighs this risk, but being aware of the warning signs, and reporting them promptly, gives you and your care team the best chance of protecting your hearing.

If you're starting a medication known to carry ototoxic risk, don't hesitate to ask your doctor about it directly, and consider a baseline hearing test if it's appropriate for your situation. Catching changes early makes a real difference in outcomes.

FAQs About Ototoxic Medications

1. What is ototoxicity? Ototoxicity is damage to the inner ear, affecting hearing, balance, or both, caused by certain medications or chemicals.

2. What are the most well-known ototoxic medications? Aminoglycoside antibiotics, certain platinum-based chemotherapy drugs, some loop diuretics, high-dose aspirin, and quinine are among the most well-documented ototoxic medications.

3. Is ototoxic hearing damage always permanent? Not always. Some ototoxic effects, particularly from high-dose aspirin, are reversible once the medication is reduced or stopped, while others, especially from certain chemotherapy drugs or antibiotics, can be permanent.

4. What are the early warning signs of ototoxicity? Early signs include new or worsening tinnitus, difficulty understanding speech, a sense of muffled hearing, new dizziness, or unsteadiness that corresponds with starting or increasing a medication.

5. Who is at higher risk for ototoxic medication effects? People on higher doses or longer treatment courses, those with kidney impairment, those using multiple ototoxic medications together, and those with pre-existing hearing loss are at higher risk.

6. Should I get a hearing test before starting a potentially ototoxic medication? For medications with significant known ototoxic risk, a baseline hearing test is often recommended and worth discussing with your doctor.

7. Can I stop a medication myself if I notice hearing changes? No, you should never stop a prescribed medication on your own. Report any new hearing or balance symptoms to your prescribing doctor promptly so they can guide next steps.

8. Do all patients on these medications develop hearing problems? No, most patients don't. Ototoxic effects depend on factors like dose, duration, kidney function, and individual sensitivity, so risk varies significantly between patients.

9. Are chemotherapy-related hearing changes monitored during treatment? Yes, for chemotherapy drugs with well-established ototoxic risk, hearing monitoring is often built into the treatment protocol to catch early changes.

10. What should I do if I'm worried about a medication's effect on my hearing? Talk directly with your prescribing doctor about the specific medication's ototoxic risk, and consider an ENT evaluation if you're experiencing hearing or balance symptoms.

Dr. Raj Bhayani is an ENT specialist focused on hearing preservation and related conditions. This article is for educational purposes and does not replace a personal medical evaluation. Never stop or adjust a prescribed medication without consulting your doctor. If you're experiencing hearing or balance symptoms while on medication, please consult your prescribing doctor and a qualified ENT

[victorianhearing]

Understanding Ototoxicity: Causes, Symptoms, Treatment Options

Learn about ototoxicity, its causes, signs, symptoms & treatment options. Book an appointment to address hearing issues & explore treatment solutions.

[jcrmhscasereports]

Diuretics use in patients with Acute Renal Failure and Septic Shock by Dr Dale Ventour in Journal of Clinical Case Reports Medical Images and Health Sciences 

ABSTRACTS

Loop diuretics should be administered in the ‘de-resuscitative’ of sepsis, this occurs after the initial resuscitative period during sepsis. The dose of diuretic should be monitored and a continuous infusion of furosemide, which is the most prescribed diuretic, should be no greater than 4mg/min.

There needs to be caution with co-administered nephrotoxic agents such as aminoglycosides, other diuretics, NSAIDS as these increase the toxicity profile. Despite the popular use of loop diuretics in critical care, loop diuretic use in sepsis has not been shown to decrease patients’ mortality.

This manuscript aims to discuss the use of diuretics in patients with septic shock exploring the evidence and consensus about the use of this therapy in critically unwell patients.

KEYWORDS: loop diuretics, septic shock, oliguria, ototoxicity, renal failure, critical care.

INTRODUCTION

Loop diuretics can be used in critical care to manipulate urine output in patients with hypoperfusion. Loop diuretics benefit the renal medulla during hypoxia by decreasing the tubular energy requirements(1, 2), which makes it a very attractive addition for patients with septic hypoperfusion. A Meta-analysis by K M Ho et al 2006 did not find in reduction in in-hospital mortality, requirement for dialysis, length of stay or number of patients remaining oliguric(3). A positive diuretic response to furosemide may indicate that the patient is in the ‘de-resuscitative’ phase of sepsis and that renal impairment is less severe. It is also appreciated that patients with non-oliguric renal failure have a lower mortality than patients with oliguric renal failure(4). The timing, duration, and dosing of diuretic therapy, plays a significant role in the morbidity associated with diuretic therapy in sepsis.

Diuretics in critical care; is used as a prophylactic measure that is, to prevent the onset of renal failure; to alleviate renal impairment in patients with established renal compromise or to convert oligo uric to non-oligo uric renal failure. There was no evidence in the meta-analysis by Ho et al 2006 that there was any benefit in the above listed uses of diuretics(3).  There was great heterogeneity between groups in this analysis and most patients had existing renal impairment so that extrapolation to critical care patients with sepsis is problematic.

The goal of transitioning a septic patient from oligemic to non-oligemic renal failure is associated with a decreased mortality trend and diuretic therapy might aid patients with regard to normalizing positive fluid balances (5) but this intervention has associated risks and complications.

Diuretic therapy should be initiated not based on urine output but when the patient has transitioned from the early resuscitative phase to the “de-resuscitative” phase of septic shock. The transit point is determined clinically as the patient is no longer fluid responsive as per passive leg raises or with static/dynamic cardiac output monitoring, is less academic and inotropic support has stabilized or decreased.

Why does this matter?

There are associated side effects when initiating diuretic therapy in critically unwell patients such as ototoxicity, hypernatremia, hypotension and worsening renal function.

OTOTOXICITY

There is changes in the endolymph ionic concentration and fluid composition secondary to the inhibition of the Na-K-2Cl transporter within the stria vascularis of the inner ear(6). Aminoglycoside antibiotics potentiate furosemide ototoxicity, but noise trauma apparently does not. Methods of avoiding ototoxicity are suggested including slow continuous infusion rather than bolus injection, use of divided oral dose regimens, and the measurement of blood levels to avoid exceeding 50 mcg/ml of furosemide(6).

In heart failure patients as outlined by Salvador et al 2005(7), continuous infusions of furosemide resulted in a lower incidence of ototoxicity and fewer side effects. Continuous infusions resulted more than 30% increase in sodium excretion than bolus administration.

The ototoxicity induced by furosemide can be reversible although permanent deafness has been reported. The complication is related to both the peak serum drug concentration  and the accumulated dose from continuous infusion and is aggravated with the concurrent use of aminoglycosides or Non-Steroid Anti-Inflammatory Drugs. The maximum recommended infusion dose is 4 mg/min (8).

HYPERNATREMIA

Hypernatremia as outlined by Hai-bin Ni et al 2016(9) was associated with increased mortality whether or not it was associated with diuretic use, this is a common side-effect with liberal diuretic use within the Intensive Care.

Hypernatremia as an independent predictor of mortality regardless of aetiology, speciality and across patients with different ages and co-morbidities (10-14). Risk factors include advancing age, co-existent renal impairment, associated use of nephrotoxic drugs. The phenomenon is poorly understood but correction is based on balancing renal water loss with overcorrection with isotonic solutions versus hypotonic water correction.

It necessities the use of Nasogastric water, naturetics, 5% Dextrose administration, low sodium enteral feeds and re-constituting drugs with 5% Dextrose rather than saline to correct this electrolyte imbalance. These interventions further complicates the management of the critically unwell patient, prevention is of tantamount importance.

WORSENING RENAL FUNCTION

Numerous studies have indicated that there is no benefit in the use of diuretic therapy to improve outcomes in patients with established acute renal failure in Intensive Care (15, 16). Maeder et al 2012, indicated a trend toward worsening renal function in elderly patients with chronic renal failure within a medical Intensive Care(17). His definition of chronic renal failure was >0.5 mg/dl increase in baseline creatinine over the 6 months follow up, again the findings not only supported renal failure as an independent predictor of mortality, but it was also aggravated by escalating the loop diuretic dose [17].

HOW DO WE ADMINISTER LOOP DIURETICS?

Meta-analyses support the administration of loop diuretics as continuous infusions versus boluses as there is better diuresis at a lower cumulative dose(18), this will inevitably lead to fewer side effects and more efficient fluid balance.

It has been suggested that the infusion dose be limited to 4mg/min to minimize the side effect profile as the loop diuretic has a ceiling effect around this dose [9]. It is also proposed by this author that the diuretic be administered in the ‘de-resuscitative’ phase of sepsis to manage the patient’s overall fluid balance.

The use of diuretics should be for the shortest time possible as there are considerations for electrolyte abnormalities and ototoxicity with a clear focus on serum sodium to gauge the amount of free water loss. While I am not against the administration of loop diuretics in septic patients with acute renal failure the timing of administration of the drug class with the “de-resuscitative phase of sepsis” is vitally important.

DISCUSSION

There is a paucity of evidence supporting the use of loop diuretics in septic critically unwell patients with acute renal failure leading to improved mortality(19, 20). These studies have highlighted increased risk of complications such as electrolyte disturbance without reducing the need for continuous renal replacement therapy or the duration of renal replacement.

Ototoxicity remains an underreported complication as there can be other contributing factors for altered hearing after the critical care episode. This complication will contribute to a patient’s post critical care morbidity affecting patient and patient’s family quality of life.

The is wide variation with the timing, dose, and indication for diuretic therapy in critical care. Bolus administration, low-dose continuous infusions (20) or high dose titrated to urine output or daily fluid balance are all methods used to administer diuretics. Liborio et al in his observational study of over 14,000 patients found no decreased mortality in critically ill patients with over 60% of these patient experiencing sepsis with a dose of furosemide up to 80 mg/day(21)

CONCLUSION

The indication and use of diuretics in septic patients with oliguric acute renal failure is varied and confounded by timing and effective dosage. However, there are significant complications associate with the use of diuretics in the critical care population and need serious considerations prior initiation of this therapy as there is no mortality benefit in septic patients with acute kidney injury.

Acknowledgement: No acknowledgement

For more information: https://jmedcasereportsimages.org/about-us/

For more submission : https://jmedcasereportsimages.org/

[greatlifegifts]

Silence and your hearing

Silence and your hearing

My great-grandmother, Hannah Schwarck Price, was a strong, resourceful woman who was profoundly deaf. This resourcefulness was forced on her through her hearing loss and a husband who abandoned her to raise their children. A woman who was a divorcee in the late early 1900s was uncommon. A single parent with a significant disability was even more rare.

Elderly woman wearing a hearing aid

Despite…

View On WordPress

[narkito]

I have a bit of a cold and a headache so I can't concentrate for more than 2 minutes at a time and it occurred to me I never put in writing what happened after that ear infection that made me lose my hearing temporarily. Long story short, it's permanent now, but it's mild and it's a rare kind of hearing loss so a speech therapist I work with went bonkers when I casually mentioned the results of my audiometry. She said she had only seen this kind of results on textbooks before and it made me feel like a freak, but hey, I'm kinda used to that by now. I wish I could say I'm never taking this bloody antibiotics again, but as I'm allergic to penicillin now, I'm gonna shut up and cross my fingers. Also, because I have a hypersensitivity to sounds (and by asking more questions they -as in the professionals measuring stuff about my ears - realised I have hypersensitivity to a whole bunch of stimuli) they strongly recommended I go to an occupational therapist. So yeah, that, I lost about 30 to 40 dB on both ears, one high frequency on one side and two high frequencies on the other. I didn't understand shit of what people were saying to me before, now I understand even less *thumbs up*

[narkito]

I’m guessing the cold does something to my ears, because I’m back to hearing shit... well, I can “hear” the walls around me, so that’s nice, but without background noise I start to feel really alone in the world and I can’t hear anything beyond the room I’m in.