A 58-year-old man comes to the office due to muffled hearing and difficulty understanding speech over the past several weeks. Medical history includes hypertension, coronary artery disease, ischemic cardiomyopathy, and chronic kidney disease. He has had repeated hospitalizations for acute heart failure decompensation and was recently treated for acute prostatitis. Vital signs are within normal limits. Otoscopic examination shows no abnormalities. Audiometry reveals symmetric high-frequency sensorineural hearing loss. Which of the following medications is the most likely cause of this patient's current symptoms?

Question

A 58-year-old man comes to the office due to muffled hearing and difficulty understanding speech over the past several weeks.  Medical history includes hypertension, coronary artery disease, ischemic cardiomyopathy, and chronic kidney disease.  He has had repeated hospitalizations for acute heart failure decompensation and was recently treated for acute prostatitis.  Vital signs are within normal limits.  Otoscopic examination shows no abnormalities.  Audiometry reveals symmetric high-frequency sensorineural hearing loss.  Which of the following medications is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

Ototoxic medications may cause damage to multiple structures of the cochlea, resulting in sensorineural hearing loss that may be irreversible, beginning in the high frequencies. Some of the most notable ototoxic medications (based on incidence of ototoxicity and frequency of use) are aminoglycoside antibiotics, chemotherapeutic agents (cisplatin), and high-dose salicylates. In addition to hearing loss, patients can also have tinnitus or balance difficulties. Management involves obtaining a formal audiogram and, if possible, ceasing the offending medication. This patient who has had multiple hospitalizations for acute heart failure decompensation was likely treated with high doses of oral and IV furosemide, which can cause hearing loss. The risk of ototoxicity from loop diuretics is greater in patients who have coexistent renal failure (as in this patient), those taking high doses of diuretics (as is likely in this patient with chronic kidney disease and multiple recent hospitalizations), and those who also take other potentially ototoxic medications. (Choice A) Aspirin may cause tinnitus and in very high doses (6-8 grams/day) can cause hearing loss. This patient is not likely to be taking supratherapeutic doses of aspirin; therefore, his hearing loss is more likely to be associated with loop diuretics. (Choice B) Ciprofloxacin may have been used to treat this patient's episode of prostatitis. Some antibiotics (most notably aminoglycosides) are ototoxic, but ciprofloxacin is not. (Choice D) Metolazone is a thiazide diuretic that may be used in combination with loop diuretics for heart failure. Adverse effects include hyponatremia and hypokalemia, but thiazides are not associated with ototoxicity. (Choice E) Sacubitril-valsartan may be used to treat advanced heart failure. Common adverse effects include hyperkalemia, hypotension, and cough, but not hearing loss. Educational objective: Loop diuretics can cause hearing loss that may be either temporary or permanent. Ototoxicity is more common in patients taking high doses of loop diuretics, those with coexistent renal failure, or those also being treated with other known ototoxic medications (eg, aminoglycosides). References: Ototoxic effects and mechanisms of loop diuretics. (http://www.ncbi.nlm.nih.gov/pubmed/29937824)

A 58-Year-Old Man Comes to the Office Due to Muffled