A 72-year-old woman presents with difficulty hearing. She was admitted 1 week ago for dyspnea, orthopnea, and bilateral leg swelling which has been slowly improving with treatment. Her family members report that for the past 2 days, she has been turning her TV volume higher and they have to speak loudly for her to hear. Her hearing was normal prior to the hospitalization. Her medical problems include hypertension, heart failure, and chronic kidney disease. Examination shows moderate bilateral sensorineural hearing loss. Which of the following medications most likely contributed to this patient's hearing impairment?

Question

A 72-year-old woman presents with difficulty hearing.  She was admitted 1 week ago for dyspnea, orthopnea, and bilateral leg swelling which has been slowly improving with treatment.  Her family members report that for the past 2 days, she has been turning her TV volume higher and they have to speak loudly for her to hear.  Her hearing was normal prior to the hospitalization.  Her medical problems include hypertension, heart failure, and chronic kidney disease.  Examination shows moderate bilateral sensorineural hearing loss.  Which of the following medications most likely contributed to this patient's hearing impairment?

Quizplus · Accepted Answer

This patient with pulmonary and peripheral edema due to heart failure and chronic kidney disease (CKD) was likely treated with diuretics during her hospitalization. Loop diuretics (eg, furosemide, torsemide, bumetanide), the most commonly used first line agents, work by inhibiting Na/K/2Cl symporters in the ascending limb of the loop of Henle. Inhibition of similar symporters in the inner ear is believed to cause ototoxicity (tinnitus, vertigo, hearing impairment, or deafness). It usually occurs with higher dosages, preexisting CKD, rapid intravenous administration, or when used in combination with other ototoxic agents (aminoglycosides, salicylates, cisplatin). Symptoms are usually reversible but hearing impairment may be permanent in some cases. Additional side effects of loop diuretics include hypokalemia, hypomagnesemia, and hypocalcemia. (Choice A) Carvedilol is a beta blocker with alpha blocking activity. Beta blockers are not initiated during decompensated heart failure as cardiac output is dependent on sympathetic input in this state. Major side effects include bradycardia, hypoglycemia, and fatigue. (Choice B) Digoxin is used in certain patients with heart failure due to systolic dysfunction to help improve symptoms. Toxicity can cause cardiac arrhythmias, hyperkalemia, nausea, vomiting and confusion. (Choice D) Hydrochlorothiazide is most often used for treating hypertension. Side effects of HCTZ include hypokalemia, hyponatremia and hypomagnesemia, and hypercalcemia. (Choice E) Ramipril is an angiotensin converting enzyme inhibitor that is used in the treatment of hypertension and is beneficial in patients with heart failure. Side effects include cough, hyperkalemia and, less frequently, angioedema and anaphylactoid reactions. (Choice F) Spironolactone works by antagonizing the effects of aldosterone in the distal tubule and collecting duct. Common side effects include hyperkalemia, gynecomastia, impotence, and decreased libido. Educational objective: Ototoxicity secondary to loop diuretics usually occurs with higher dosages, pre-existing chronic renal disease, rapid intravenous administration, or when used in combination with other ototoxic agents (aminoglycosides, salicylates, and cisplatin). Hearing impairment is usually reversible but may be permanent in some cases. __________ References: Systemic ototoxicity: a review. (http://www.ncbi.nlm.nih.gov/pubmed/16450683)

A 72-Year-Old Woman Presents with Difficulty Hearing