Important

Before reading this information sheet it is important to note that no-one should stop taking any medication or alter the dosage of their medication without first discussing it with their general practitioner, primary care physician or the doctor who prescribed the medication.

 

Drugs and tinnitus

Many people with tinnitus worry that certain drugs or medicines may have caused their tinnitus. A browse through a medical textbook or a search on the internet would seem to reinforce that view as there are numerous reports of tinnitus being associated with medication. In fact, when these claims are subjected to proper scientific scrutiny the number of drugs that genuinely cause tinnitus is extremely small. Even those drugs that do cause tinnitus tend to result in temporary tinnitus: once the drug is discontinued the tinnitus usually disappears. Also, where drugs do cause tinnitus the effect is usually dose dependent. In other words, the normal dose that a doctor would prescribe does not cause tinnitus. It is only unusually large doses that result in tinnitus.

Why is it that there are so many reports of drugs causing tinnitus but so few scientifically confirmed cases? The reasons for this apparent contradiction are interesting. Firstly tinnitus is common and taking medication for one condition or another is also common. It is therefore inevitable that there should be some coincidences and some people will develop their tinnitus while taking certain drugs. They may then blame the drug even though it is blameless. If the patient reports this to their general practitioner the doctor has a duty to fill in a report card and send it to an organisation called the Committee on Safety of Medicines. The information is then stored so that other doctors can access it to advise their patients. Thus a single report of tinnitus can label a drug as a “tinnitus causer” even though the tinnitus may have been coincidental to taking the medication. There is another way that drugs may get accused of causing tinnitus: drugs are administered to treat medical conditions or illnesses. Having the illness that requires treatment is a stressful event. Stress is a well recognised trigger for tinnitus and consequently in many cases it is the stress of the illness rather than the drug used to treat the illness that triggers the tinnitus.

 

Specific drugs and tinnitus

Nonetheless, there are a small number of drugs that do cause tinnitus. Many of these drugs are only given for serious illnesses where there is no alternative and once again the BTA would like to stress that no-one should alter their medication without first discussing it with the prescribing doctor.

• Aspirin

In the normal small doses used to treat headaches or ‘flu it is very unlikely that aspirin will cause tinnitus. Similarly the tiny doses of aspirin that many middle aged and elderly people take to prevent heart attacks or strokes are extremely unlikely to result in tinnitus. Aspirin used to be used in much larger doses to treat some rheumatological conditions and when given at these very high doses tinnitus sometimes did occur. However this effect was generally reversible: once the aspirin was stopped or the dosage reduced, the tinnitus disappeared. Such large doses of aspirin are almost never used nowadays as there are more effective, modern, alternative drugs available to treat these conditions. A very small number of people are unusually sensitive to aspirin and develop reversible tinnitus at very low doses. Clearly such people should avoid aspirin and contact their doctor for advice regarding alternative drugs.

• Quinine

Quinine and chloroquine can occasionally cause permanent damage to the ear when given in high or prolonged doses, such as in the treatment of malaria. However, taken in low doses to prevent malaria or to relieve night cramps, this does not happen. A few people on these low doses of quinine do report tinnitus but this is temporary and ceases as soon as they discontinue the medication.

• Aminoglycoside antibiotics

There is a small group of very specialised, powerful antibiotics that can be ototoxic – in other words they can damage the inner ear. This damage can cause hearing loss and a small number of the affected people develop tinnitus as a consequence of this hearing loss. This group includes streptomycin and gentamicin. These drugs are not available as tablets, syrups or other oral preparations and are generally given by injection in hospital for severe, life threatening infections. Damage to the ear only occurs when the amount of the drug in the blood stream exceeds certain levels. For this reason the level is closely monitored by regular blood tests. However, there are certain conditions such as renal failure when the level of the drug can rise unpredictably and allow dangerous levels to be reached. In these rare circumstances, tinnitus can occur. Aminoglycosides are also a component of some ear drops. These ear drops are only available on prescription: all the ear drops that can be purchased at a pharmacy without a prescription in the United Kingdom do not contain aminoglycosides. Although there is a theoretical risk, aminoglycoside ear drops do not generally cause ear damage and ear specialists are happy to prescribe them in reasonably short courses. However, any patient who is worried about taking such drops should discuss the matter with their doctor – there may be an alternative.

• Cytotoxic drugs

The other main group of drugs which can damage the inner ear are the cytotoxic drugs used in treating cancer. Despite the power of such drugs, damage to the ear is surprisingly uncommon. The main group of cytotoxic drugs that can damage the ear is the group containing platinum, including cisplatin and, to a lesser extent, carboplatin and oxaliplatin. The specialist doctors who prescribe such drugs are very well aware of their potential side effects and usually discuss the matter in great detail prior to treatment. Also, where possible, patients receiving such drugs will have their hearing tested on a regular basis to identify any ear damage at an early stage, before any serious deterioration occurs.

• Diuretics

Some other drugs which are occasionally ototoxic are a group of drugs called loop diuretics which are used to increase the production of urine in the treatment of high blood pressure, heart failure and some kidney disorders. Ototoxicity only occurs with large doses and the relatively small dose given for mild or moderate high blood pressure does not cause damage to the ear. Even with large doses such diuretics probably only cause permanent damage when used in combination with other ototoxic drugs.

 

Idiosyncratic drug reactions

Although the vast majority of drugs do not cause tinnitus in most patients there is a small group of patients who will have an unexpected – or idiosyncratic – reaction to their medication. Any patient who suspects this should discuss the matter with their doctor. There may well be a suitable alternative medication or a different dosage regime that may help.

 

Food and drink

A number of people with tinnitus associate fluctuations of their tinnitus with taking certain foods or drinks. Thus some people find that alcohol, drinks containing caffeine, or foods such as cheese may worsen their tinnitus. However, an equivalent number of people find that these same substances will actually improve their tinnitus! There does not seem to be any food or drink that definitely causes or exacerbates tinnitus in every person. Whatever reaction someone with tinnitus might notice is likely to be a personal idiosyncratic reaction. Unfortunately there is no simple test for such reactions. The only way of determining if a foodstuff does affect the tinnitus is to remove it from the diet and then reintroduce it as a challenge. Sometimes it is difficult to identify the likely culprit. In these circumstances it may help to keep a diary of what is eaten and drunk and see if there is any relationship between bad periods of tinnitus and individual foods and drinks. The diary may have to be detailed, specifying what type of meat, vegetable, cheese, fish, wine, and so on, as one particular type of vegetable, for example, may aggravate the tinnitus, where others have no effect. If the diary suggests a particular food or drink, that food or drink should be avoided for a period of seven days. Then the system should be challenged by reintroducing that food or drink, withdrawing it, re-challenging, and withdrawing again. Tinnitus can fluctuate so much that the tests should be repeated several times. Relying on a single trial withdrawal may end up denying a person some item of food or drink that they would otherwise enjoy and in fact has no adverse effect on the tinnitus anyway. Similarly, well meaning but unjustifiable generalised advice is often repeated in books and articles on tinnitus, suggesting that people should give up tea, coffee, red wine, etc. Removing such items from the diet often brings no benefit and the lack of enjoyment of that food or drink then merely adds to the burden of tinnitus. It is important to issue a further word of warning at this point: keeping diaries and going on exclusion diets can sometimes be counterproductive as it encourages people to monitor their tinnitus, which can in turn make it seem louder.

 

Tobacco and recreational drugs

Although the BTA cannot condone the use of such substances, there is no evidence that tobacco, marijuana, ecstasy, cocaine and other recreational drugs have any major impact for good or ill on tinnitus. If someone with tinnitus feels that one of these substances is making their tinnitus worse, they should go through the same withdrawal/challenge process as described above for foodstuffs.