by Neil Bauman, Ph.D.
February 19, 2016
A man explained,
I have profound sensorineural hearing loss and don’t want to lose any more hearing because that could change my life! I have been diagnosed with prostatitis (prostate infection) and I showed my doctor your book. We decided against Tetracycline (class 3) in favor of Bactrim, a combination of Trimethoprim (class 1) and Sulfamethoxazole (class 2). Do you agree with this? Also, is it better to take one pill morning and night for three weeks, or two pills morning and night for two weeks? Thank you so much for your expert insight!
You are doing a wise thing—taking my book, “Ototoxic Drugs Exposed” with you to your doctor and then the two of you working together to choose the least ototoxic drug that will do the job. That way you can best protect your precious remaining hearing.
You narrowed the choices down to two drugs, and then chose the one with the lesser ototoxicity. If these were your only two choices, I think you have made the better choice.
However, I think you could have made an even better choice if you had considered other drugs in the same class as Trimethoprim (Bactrim). You’ll notice that Trimethoprim is in a class of drugs called Urinary Anti-infectives (7.20).
If you turn to Table 14-1, and classification 7.20 you’ll see that there are four drugs listed. Did you and your doctor consider each of the choices there?
In addition to Trimethoprim, Nitrofurantoin (MacroBID) is also listed there. Notice that it does not have any cochlear side effects (such as tinnitus, hyperacusis or hearing loss) listed. [Updated Dec 2023—I have now found a lot more ototoxic side effect data on many drugs since I originally wrote this that changes what I have said here. For example, I have now listed Nitrofurantoin as causing both hearing loss and tinnitus (among other ototoxic side effects—N.B.).]
Since you don’t want to mess up any of your remaining hearing, given the choice, I’d stay away from any drug that has any cochlear side effects.
As you know, Bactrim is a combination of two drugs—Trimethoprim (which also does not have any cochlear side effects) and Sulfamethoxazole (which has tinnitus listed as a cochlear side effect).
Thus Bactrim has a slight chance of giving you tinnitus, whereas taking Nitrofurantoin doesn’t. Thus, if given the choice, taking Nitrofurantoin would be an even better choice from your ears point of view if your doctor thinks it will be as effective as the Bactrim.
It’s always wise to check out as many choices as you can to find the least ototoxic drug that will do the job.
Now to answer your question on the two dosage options—an excellent question by the way. Here’s some guidelines to help you choose wisely.
I have three guidelines when it comes to taking drugs.
- Take the least ototoxic drug.
- Take the lowest dose possible.
- Take it for the shortest effective time.
Above, we considered point 1. Now lets look at points 2 and 3.
Your options were:
- take 1 pill twice a day for 3 weeks. The total would be 2 x 21 days = 42 pills in total.
- take 2 pills twice a day for 2 weeks. The total would be 4 x 14 days = 56 pills in total.
Therefore, for point 2, the lowest dose would be the first one above—taking 42 pills. This would give you a lower cumulative dose, which should be less ototoxic.
Although this option gives the lower total dose, it spreads it out over a longer time. This flies in the face of my point 3 guideline—take if for the shortest time possible. Here’s how I rationalize between these two conflicting options.
Very often drugs have what I call a “magic threshold” in terms of dose below which you don’t have any noticeable ototoxic side effects. (I call it a “magic threshold” because you don’t know what that dosage level is below which you don’t have ototoxic side effects. Furthermore, this dose may be different for each person.) Thus, taking a lower dose (1 pill at a time rather than 2 pills at a time) means that you have a much better chance of flying below the radar of this magic threshold—whatever level it is.
At the same time, you are stretching out the dose over 3 weeks instead of 2, but you are taking a lower cumulative dose—so I think those two factors balance each other out.
Thus, if it were me, I’d choose the first option and take 1 pill twice a day for 3 weeks and hope no ototoxic side effects (or any other side effects for that matter) would show up.
I have suffered sensorineural sudden hearing loss after taking Sulfamethoxazole – TMP DS160mg twice a day for 5 days in January 2015. I will now have to be treated for Lyme disease with a regimen of Amoxycilyn. Do you know of anything less ototoxic, I do want to retain my hearing on the only hearing ear I have left.
Hi Helga:
Amoxicillin is not all that ototoxic as far as antibiotics go, but it can and does cause hearing loss and tinnitus in some people, so there are no guarantees it won’t affect you. It is a drug you could try since you have to take something. However, before you do that, find out what drugs would be your doctor’s other choices? I can tell you which one is the least ototoxic of the bunch.
Cordially,
Neil
Hi – I have quite a resistant UTI – the only antibiotics it’s sensitive to are Ciprofloxacin, Gentamicin, Nitrofurantoin, Piperacillin and Tobramycin. I’ve taken one Ciprofloxacin and my tinnitis has increased dramatically. What other one on the list would you recommend instead and would you suggest the full dose or a lower dose over a longer period? Thanks…
Hi Louise:
Hands down, the least ototoxic is Nitrofurantoin. And it does not affect tinnitus as far as I know. I’ve taken it myself with no side effects.
I’m not sure it would matter in your case–full short dose or smaller but longer dose. So just go with what your doctor suggests would be the better choice.
Cordially,
Neil
Respectfully but you are dead wrong on this one. I took macrobid for 10 days for a uti and had extreme tinnitus set in within a week. I was told this would go away. This happened in 2013. Here it is now 2022 and I still have the tinnitus and hearing loss in my left ear because of this drug!
Hi Bea:
How so? The number of reports of tinnitus from taking common UTI drugs such as Nitrofurantoin, Doxycycline and Cephalexin shows Nitrofurantoin has the fewest reports. For example, compared to Doxycycline, Nitrofurantoin has only 1/4 the number of reports of tinnitus and Cephalexin is close behind it.
However, when comparing the number of prescriptions filled divided by the number of reports received, the risk of getting tinnitus from taking Nitrofurantoin is still only half as common. So I stick by my recommendations.
Note, this is the risk factor–how likely you are to get tinnitus, not how bad any resulting tinnitus might be. This means that people taking Nitrofurantoin can still get severe tinnitus from it. It is just not as likely as with other UTI drugs. You were one of those unfortunate people. But that doesn’t make Nitrofurantoin bad, or my advice wrong.
Cordially,
Neil
Hi Dr. Neal,
I have had tinnitus from taking Gabapentin for unsuccessful neck surgery,4 years ago. I am taking this to counteract the problems with constipation.
Have you heard of this causing tinnitus.
So glad I found this website I have got my first book written by you.
Blessings
Nancy M,
Hi Nancy:
Yes, Gabapentin is known to cause tinnitus in numbers of people. I’ve heard from a number of them with stories similar to yours.
Cordially,
Neil
Hello, Neil.
I have been prescribed a number of Antibiotics for a number of infections. Currently taking them for Acne. Ear fullness is a very common side effect for me. I had been taking Oxytetracycline for 8 months (all good!!), but it stopped working for me. Currently taking Zineryt (Erythromcin?). It’s been a week and i can feel it happening again. Is there another drug that you would recommend?
-Boris
Hi Boris:
I don’t recommend taking any antibiotics for more than 2 weeks. They are hard on your body and your immune system.
Cordially,
Neil
I was prescribed Keflex after Macrobid “almost” nailed my UTI. UTI back within days, MD prescribed Keflex. Question, since Keflex is ototoxic, would it be safe to take just one pill for one day? If the UTI almost died, then perhaps just one more day of an antibiotic would kill it.
Hi Neil,
My 14 year old son has been diagnosed with H pylori bacteria from a stool sample. His doctor had already prescribed omeprazole to control the stomach acid & prochlorperazine to help with the feeling of sickness before his diagnosis.
His doctor has now prescribed amoxicillin, clarithromycin & omeprazole to fight the bacterial infection.
he has also been recently treated for a blocked left ear which when the wax was removed revealed an eczema/psoriasis which is being treated with sofradex drops in the ear.
My question & concern is should he take the suggested coarse of antibiotics whilst currently taking the antibiotic drops for the ear infection & also would there be a less ototoxic combination of drugs to take to treat the h pylori infection.
Current he is experiencing feelings of dizziness although i’m unsure if this is due to the ear infection/medicine or the fact that the prochlorperazine & omeprazole may be causing him dizziness.
Would really welcome any help from a confused & worried parent….
Hi Peter:
I don’t like the idea of taking all those ototoxic drugs–all of them can cause dizziness, tinnitus, etc., etc.
Sofradex contains Framycetin (an aminoglycoside). I am very wary of any of the aminoglycosides as they can easily wreck ears. Surely there are less ototoxic preparations they could prescribe.
I don’t know exactly what he has in his ear canal, but I’d think things like hydrogen peroxide or apple cider vinegar in water would do the trick–or at least try them first rather than going for the “big guns”.
If it were me, I wouldn’t take any of the drugs for the H. pylori until I had tried all the natural remedies and found they didn’t work for me.
Here is what on doctor recommends as natural remedies.
https://draxe.com/health/h-pylori/
You can find others by putting in “natural remedies for H. pylori” in Google. Most of the natural ones are similar to the one above.
I’d think his dizziness is from one ore more of the drugs.
Cordially,
Neil
Hello doctor , I have hearing loss from loud noise exposure and recently been tested for UTI , if positive is macrobid safe to take for the UTI as I do not want to mess up my ears further , thank you so much!
Sal
Hi Sal:
As far as antibiotics go for UTIs, the rate Nitrofurantoin (MacroBID) as one of the least ototoxic. It is mildly ototoxic, so there is still a risk, but I believe it is quite small. I’ve taken this drug myself with no problems.
Cordially,
Neil
Hi Neil,
If you have an ototoxic reaction to a drug, is it usually permanent? And is the reaction usually immediate?
Thanks in advance.
Hi Caroline:
Your questions can’t be answered simply “yes” or “no”. This is a very complex topic. The real answer is “it depends”.
Whether a drug side effect is permanent depends on the exact side effect, the drug you take, you body physiology, your emotional reaction, etc., etc.
For example, you may initially experience dizziness from a given drug. But as your body gets used to it, the dizziness may disappear. The same drug may also cause hearing loss–and if the hearing loss is due to the death of some hair cells, then the hearing loss will be permanent. If you get tinnitus as a secondary result of hearing loss, the tinnitus will likely last as long as the hearing loss–in other word, be permanent. However, if tinnitus occurs by itself it may be temporary or permanent–but a lot depends on your psychological/emotional state. If you treat your tinnitus like it was a threat to your well-being, it will probably prove to be permanent, whereas if you treat it as a totally unimportant, useless background sound that is safe to ignore, and then ignore it, the chances are it will fade away in time.
I dare say that many of the ototoxic side effects of drugs prove to be temporary, but there are still enormous numbers of people who find the side effects are permanent. So much depends on the specific drug.
To answer you second question–reactions may be immediate, or show up later–sometimes a decade later, and everything in between. For example, you can get tinnitus just 7 minutes after getting an IV of Furosemide. That’s pretty immediate. You can get ototoxic side effects from taking your very first pill of Ibuprofen, while another person may take the same drug for 10 years with no apparent side effects, yet another person experiences the same side effects after taking it for several months.
Often, side effects will show up in a few days to 2 weeks. Sometimes side effects may only show up after you get off the drug after taking it for years. Benzodiazepines are notorious for this with tinnitus.
The only way to avoid drug side effects is not to take drugs. However if you NEED to take a drug (not just “let’s see if this works or that works”), here are my three rules of thumb to avoid as much as possible the risk of ototoxic (or other) side effects.
1. Take the least ototoxic drug that’s available.
2. Take the lowest dose that will do the job.
3. Take the drug for the shortest possible time that will do the job.
Cordially,
Neil
I was prescribed Nitrofurantoin (MacroBID) once for a bladder infection back in 2013. I developed catastrophic tinnitus during treatment which is still present to this day in 2024.