Ciprofloxacin interactions

Food & lifestyle

• dairy products

  Moderate

  Absorption

  Concurrent ingestion of dairy products (milk, yogurt) or calcium-fortified foods (i.e., cereal, orange juice) may decrease the activity of certain oral fluoroquinolone antibiotics. The mechanism is chelation of calcium and the quinolone, resulting in decreased bioavailability.

  What to do: Oral ciprofloxacin should not be taken with dairy products or calcium-fortified foods alone, but may be taken with meals that contain these products. When taken alone, dairy products or calcium-fortified foods should be ingested at least 2 hours before or after ciprofloxacin administration. When ciprofloxacin tablets are administered to patients receiving continuous enteral nutrition, some experts recommend that the tube feeding should be interrupted for at least 1 hour before and 2 hours after the dose of ciprofloxacin is given. Patients should be monitored for altered antimicrobial efficacy and switched to intravenous ciprofloxacin if necessary. If no enteral route besides a jejunostomy tube is available, it is also recommended to switch to intravenous ciprofloxacin. According to the manufacturer, ciprofloxacin oral suspension should not be administered via nasogastric or feeding tubes due to its physical characteristics.

  6 sources

  1. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  2. Yuk JH, Nightingale CH, Sweeney KR, Quintiliani R, Lettieri JT, Forst RW "Relative bioavailability in healthy volunteers of ciprofloxacin administered through a nasogastric tube with and without enteral feeding." Antimicrob Agents Chemother 33 (1989): 1118-20
  3. Yuk JH, Nightingale CH, Quintiliani R "Absorption of ciprofloxacin administered through a nasogastric or a nasoduodenal tube in volunteers and patients receiving enteral nutrition." Diagn Microbiol Infect Dis 13 (1990): 99-102
  4. Noer BL, Angaran DW "The effect of enteral feedings on ciprofloxacin pharmacokinetics." Pharmacotherapy 10 (1990): 254
  5. Neuhofel AL, Wilton JH, Victory JM, Hejmanowsk LG, Amsden GW "Lack of bioequivalence of ciprofloxacin when administered with calcium-fortified orange juice: a new twist on an old interaction." J Clin Pharmacol 42 (2002): 461-6
  6. Wohlt PD, Zheng L, Gunderson S, Balzar SA, Johnson BD, Fish JT "Recommendations for the use of medications with continuous enteral nutrition." Am J Health Syst Pharm 66 (2009): 1438-67

• orange juice

  Moderate

  Absorption

  Concurrent ingestion of dairy products (milk, yogurt) or calcium-fortified foods (i.e., cereal, orange juice) may decrease the activity of certain oral fluoroquinolone antibiotics. The mechanism is chelation of calcium and the quinolone, resulting in decreased bioavailability. In the case of orange juice, inhibition of intestinal transport mechanisms (P-glycoprotein or organic anion-transporting polypeptides) by flavones may also be involved.

  What to do: Oral ciprofloxacin should not be taken with dairy products or calcium-fortified foods alone, but may be taken with meals that contain these products. When taken alone, dairy products or calcium-fortified foods should be ingested at least 2 hours before or after ciprofloxacin administration. When ciprofloxacin tablets are administered to patients receiving continuous enteral nutrition, some experts recommend that the tube feeding should be interrupted for at least 1 hour before and 2 hours after the dose of ciprofloxacin is given. Patients should be monitored for altered antimicrobial efficacy and switched to intravenous ciprofloxacin if necessary. If no enteral route besides a jejunostomy tube is available, it is also recommended to switch to intravenous ciprofloxacin. According to the manufacturer, ciprofloxacin oral suspension should not be administered via nasogastric or feeding tubes due to its physical characteristics.

  6 sources

  1. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  2. Yuk JH, Nightingale CH, Sweeney KR, Quintiliani R, Lettieri JT, Forst RW "Relative bioavailability in healthy volunteers of ciprofloxacin administered through a nasogastric tube with and without enteral feeding." Antimicrob Agents Chemother 33 (1989): 1118-20
  3. Yuk JH, Nightingale CH, Quintiliani R "Absorption of ciprofloxacin administered through a nasogastric or a nasoduodenal tube in volunteers and patients receiving enteral nutrition." Diagn Microbiol Infect Dis 13 (1990): 99-102
  4. Noer BL, Angaran DW "The effect of enteral feedings on ciprofloxacin pharmacokinetics." Pharmacotherapy 10 (1990): 254
  5. Neuhofel AL, Wilton JH, Victory JM, Hejmanowsk LG, Amsden GW "Lack of bioequivalence of ciprofloxacin when administered with calcium-fortified orange juice: a new twist on an old interaction." J Clin Pharmacol 42 (2002): 461-6
  6. Wohlt PD, Zheng L, Gunderson S, Balzar SA, Johnson BD, Fish JT "Recommendations for the use of medications with continuous enteral nutrition." Am J Health Syst Pharm 66 (2009): 1438-67

Conditions

Conditions in which Ciprofloxacin needs care, as documented in this source.

• Central Nervous System Diseases

  Major

  Quinolones may cause CNS stimulation manifested as tremors, agitation, restlessness, anxiety, confusion, hallucinations, paranoia, insomnia, toxic psychosis, and/or seizures. Benign intracranial hypertension has also been reported. Therapy with quinolones should be administered cautiously in patients with or predisposed to seizures or other CNS abnormalities. In addition, these patients should be advised to avoid the consumption of caffeine-containing products during therapy with some quinolones, most notably ciprofloxacin, enoxacin, and cinoxacin, since these agents can substantially reduce the clearance of caffeine and other methylxanthines, potentially resulting in severe CNS reactions.

  57 sources

  1. Ball P "Ciprofloxacin: an overview of adverse experiences." J Antimicrob Chemother 18 (1986): 187-93
  2. Arcieri G, Griffith E, Gruenwaldt G, et al. "A survey of clinical experience with ciprofloxacin, a new quinolone antimicrobial." J Clin Pharmacol 28 (1988): 179-89
  3. McCue JD, Zandt JR "Acute psychoses associated with the use of ciprofloxacin and trimethoprim-sulfamethoxazole." Am J Med 90 (1991): 528-9
  4. Arcieri G, August R, Becker N, et al. "Clinical experience with ciprofloxacin in the USA." Eur J Clin Microbiol 5 (1986): 220-5
  5. Altes J, Gasco J, De Antonio J, Villalonga C "Ciprofloxacin and delirium." Ann Intern Med 110 (1989): 170-1
  6. McDermott JL, Gideonse N, Campbell JW "Acute delirium associated with ciprofloxacin administration in a hospitalized elderly patient." J Am Geriatr Soc 39 (1991): 909-10
  7. Slavich IL, Gleffe Rf, Haas EJ "Grand mal epileptic seizures during ciprofloxacin therapy." JAMA 261 (1989): 558-9
  8. Moore B, Safani M, Keesey J "Possible exacerbation of myasthenia gravis by ciprofloxacin." Lancet Jan (1988): 882

  Show all 57 sourcesShow fewer sources

  9. Semel JD, Allen N "Seizures in patients simultaneously receiving theophylline and imipenem or ciprofloxacin or metronidazole." South Med J 84 (1991): 465-8
  10. Karki SD, Bentley DW, Raghavan M "Seizure with ciprofloxacin and theophylline combined therapy." DICP 24 (1990): 595-6
  11. Schwartz MT, Calvert JF "Potential neurologic toxicity related to ciprofloxacin." Ann Pharmacother 24 (1990): 138-40
  12. Anastasio GD, Menscer D, Little JM "Norfloxacin and seizures." Ann Intern Med 109 (1988): 169-70
  13. Todd PA, Faulds D "Ofloxacin: a reappraisal of its antimicrobial activity, pharmacology, and therapeutic use." Drugs 42 (1991): 825-76
  14. Unseld E, Ziegler G, Gemeinhardt A, Janssen U, Klotz U "Possible interaction of fluoroquinolones with benzodiazepine-GABA-receptorn complex." Br J Clin Pharmacol 30 (1990): 63-70
  15. Fennig S, Mauas L "Ofloxacin-induced delirium." J Clin Psychiatry 53 (1992): 137-8
  16. Tack KJ, Smith JA "The safety profile of ofloxacin." Am J Med 87 (1989): s78-81
  17. Jaber LA, Bailey EM, Rybak MJ "Enoxacin: a new fluoroquinolone." Clin Pharm 8 (1989): 97-107
  18. Wadworth AN, Goa KL "Lomefloxacin: a review of its antibacterial activity, pharmacokinetic properties and therapeutic use." Drugs 42 (1991): 1018-60
  19. Bednarczyk EM, Green JA, Nelson D, et al. "Comparative assessment of the effect of lomefloxacin, ciprofloxacin, and placebo on cerebral blood flow, and glucose and oxygen metabolism in healthy subjects by position emission tomography." Pharmacotherapy 12 (1992): 369-75
  20. Poc TE, Marion GS, Jackson DS "Seizures due to nalidixic acid therapy." South Med J 77 (1984): 539-40
  21. Burt RA "Review of adverse reactions associated with cinoxacin and other drugs used to treat urinary tract infections." Urology 23 (1984): 101-7
  22. Norrby SR "Side-effects of quinolones: comparisons between quinolones and other antibiotics." Eur J Clin Microbiol Infect Dis 10 (1991): 378-83
  23. Fraser AG, Harrower AD "Convulsions and hyperglycaemia asociated with nalidixic acid." Br Med J 2 (1977): 1518
  24. Kremer L, Walton M, Wardle EN "Nalidixic acid and intracranial hypertension." Br Med J 4 (1967): 488
  25. Leslie PJ, Cregeen RJ, Proudfoot AT "Lactic acidosis, hyperglycaemia and convulsions following nalidixic acid overdosage." Hum Toxicol 3 (1984): 239-43
  26. Cox CE, Simmons JR "Cinoxacin therapy for urinary tract infections: therapeutic safety and efficacy." South Med J 75 (1982): 549-50
  27. Sisca TS, Heel RC, Romankiewicz JA "Cinoxacin. A review of its pharmacological properties and therapeutic efficacy in the treatment of urinary tract infections." Drugs 25 (1983): 544-69
  28. Stamey TA "Cinoxacin: an overview." Urology 17 (1981): 492-5
  29. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  30. "Product Information. Penetrex (enoxacin)." Rhone Poulenc Rorer (2002):
  31. "Product Information. Maxaquin (lomefloxacin)." Searle (2002):
  32. "Product Information. Neggram (nalidixic acid)." Sanofi Winthrop Pharmaceuticals
  33. "Product Information. Noroxin (norfloxacin)." Merck & Co., Inc (2001):
  34. "Product Information. Floxin (ofloxacin)." Ortho McNeil Pharmaceutical (2001):
  35. Just PM "Overview of the fluoroquinolone antibiotics." Pharmacotherapy 13 (1993): s4-17
  36. Akhtar S, Ahmad H "Ciprofloxacin-induced catatonia." J Clin Psychiatry 54 (1993): 115-6
  37. Isaacson SH, Carr J, Rowan AJ "Ciprofloxacin-induced complex partial status epilepticus manifesting as an acute confusional state." Neurology 43 (1993): 1619-21
  38. Getenet JC, Croisile B, Vighetto A, et al. "Idiopathic intracranial hypertension after ofloxacin treatment." Acta Neurol Scand 87 (1993): 503-4
  39. "Product Information. Cinobac (cinoxacin)." Oclassen Pharmaceuticals Inc (2001):
  40. Fanhavard P, Sanchorawala V, Oh J, Moser EM, Smith SP "Concurrent use of foscarnet and ciprofloxacin may increase the propensity for seizures." Ann Pharmacother 28 (1994): 869-72
  41. Rosolen A, Drigo P, Zanesco L "Acute hemiparesis associated with ciprofloxacin." BMJ 309 (1994): 1411
  42. Schacht P, Arcieri G, Hullmann R "Safety of oral ciprofloxacin. An update based on clinical trial results." Am J Med 87 (1989): s98-102
  43. Winrow AP, Supramaniam G "Benign intracranial hypertension after ciprofloxacin administration." Arch Dis Child 65 (1990): 1165-6
  44. Thomas RJ, Regan DR "Association of a tourette-like syndrome with ofloxacin." Ann Pharmacother 30 (1996): 138-41
  45. Traeger SM, Bonfiglio MF, Wilson JA, Martin BR, Nackes NA "Seizures associated with ofloxacin therapy." Clin Infect Dis 21 (1995): 1504-6
  46. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):
  47. "Product Information. Zagam (sparfloxacin)." Rhone Poulenc Rorer (2001):
  48. Ernst ME, Ernst EJ, Klepser ME "Levofloxacin and trovafloxacin: the next generation of fluoroquinolones?" Am J Health Syst Pharm 54 (1997): 2569-84
  49. "Product Information. Trovan (trovafloxacin)." Pfizer U.S. Pharmaceuticals (2001):
  50. Haria M, Lamb HM "Trovafloxacin." Drugs 54 (1997): 435-45;disc. 446
  51. Walton GD, Hon JK, Mulpur TG "Ofloxacin-induced seizure." Ann Pharmacother 31 (1997): 1475-7
  52. "Product Information. Avelox (moxifloxacin)." Bayer (2001):
  53. "Product Information. Tequin (gatifloxacin)." Bristol-Myers Squibb (2001):
  54. Melvani S, Speed BR "Alatrofloxacin-induced seizures during slow intravenous infusion." Ann Pharmacother 34 (2000): 1017-9
  55. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  56. De Sarro A, De Sarro G "Adverse reactions to fluoroquinolones. An overview on mechanistic aspects." Curr Med Chem 8 (2001): 371-84
  57. "Product Information. Baxdela (delafloxacin)." Melinta Therapeutics, Inc. (2017):

• Colitis

  Major

  Clostridioides difficile-associated diarrhea (CDAD), formerly pseudomembranous colitis, has been reported with almost all antibacterial drugs and may range from mild diarrhea to fatal colitis. The most common culprits include clindamycin and lincomycin. Antibacterial therapy alters the normal flora of the colon, leading to overgrowth of C difficile, whose toxins A and B contribute to CDAD development. Morbidity and mortality are increased with hypertoxin-producing strains of C difficile; these infections can be resistant to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea after antibacterial use. Since CDAD has been reported to occur more than 2 months after antibacterial use, careful medical history is necessary. Therapy with broad-spectrum antibacterials and other agents with significant antibacterial activity should be administered cautiously in patients with history of gastrointestinal disease, particularly colitis; pseudomembranous colitis (generally characterized by severe, persistent diarrhea and severe abdominal cramps, and sometimes associated with the passage of blood and mucus), if it occurs, may be more severe in these patients and may be associated with flares in underlying disease activity. Antibacterial drugs not directed against C difficile may need to be stopped if CDAD is suspected or confirmed. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C difficile, and surgical evaluation should be started as clinically indicated.

  31 sources

  1. "Product Information. Omnipen (ampicillin)." Wyeth-Ayerst Laboratories (2002):
  2. "Product Information. Ceftin (cefuroxime)." Glaxo Wellcome (2002):
  3. "Product Information. Zinacef (cefuroxime)." Glaxo Wellcome (2002):
  4. "Product Information. Cleocin (clindamycin)." Pharmacia and Upjohn (2002):
  5. "Product Information. Macrobid (nitrofurantoin)." Procter and Gamble Pharmaceuticals (2002):
  6. "Product Information. Macrodantin (nitrofurantoin)." Procter and Gamble Pharmaceuticals (2002):
  7. "Product Information. Amoxil (amoxicillin)." SmithKline Beecham (2001):
  8. "Product Information. Merrem (meropenem)." Astra-Zeneca Pharmaceuticals (2001):

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  9. "Product Information. Coly-Mycin M Parenteral (colistimethate)." Parke-Davis (2001):
  10. "Product Information. Lincocin (lincomycin)." Pharmacia and Upjohn (2001):
  11. "Product Information. Cubicin (daptomycin)." Cubist Pharmaceuticals Inc (2003):
  12. "Product Information. Xifaxan (rifaximin)." Salix Pharmaceuticals (2004):
  13. "Product Information. Doribax (doripenem)." Ortho McNeil Pharmaceutical (2007):
  14. "Product Information. Penicillin G Procaine (procaine penicillin)." Monarch Pharmaceuticals Inc (2009):
  15. "Product Information. Vibativ (telavancin)." Theravance Inc (2009):
  16. "Product Information. Teflaro (ceftaroline)." Forest Pharmaceuticals (2010):
  17. "Product Information. Penicillin G Sodium (penicillin G sodium)." Sandoz Inc (2022):
  18. "Product Information. Dalvance (dalbavancin)." Durata Therapeutics, Inc. (2014):
  19. "Product Information. Orbactiv (oritavancin)." The Medicines Company (2014):
  20. "Product Information. Bicillin C-R (benzathine penicillin-procaine penicillin)." A-S Medication Solutions (2017):
  21. "Product Information. Baxdela (delafloxacin)." Melinta Therapeutics, Inc. (2017):
  22. "Product Information. Polymyxin B Sulfate (polymyxin B sulfate)." AuroMedics Pharma LLC (2022):
  23. "Product Information. Zemdri (plazomicin)." Achaogen (2018):
  24. "Product Information. Seysara (sarecycline)." Allergan Inc (2018):
  25. "Product Information. Nuzyra (omadacycline)." Paratek Pharmaceuticals, Inc. (2018):
  26. "Product Information. Aemcolo (rifamycin)." Aries Pharmaceuticals, Inc. (2018):
  27. "Product Information. Fetroja (cefiderocol)." Shionogi USA Inc (2019):
  28. "Product Information. Biaxin (clarithromycin)." AbbVie US LLC (2019):
  29. "Product Information. Zithromax (azithromycin)." Pfizer U.S. Pharmaceuticals Group (2021):
  30. "Product Information. E.E.S.-400 Filmtab (erythromycin)." Arbor Pharmaceuticals (2018):
  31. "Product Information. Priftin (rifapentine)." sanofi-aventis (2020):

• Long QT Syndrome

  Major

  Quinolones have been reported to prolong the QT interval of the electrocardiogram in some patients. QT prolongation may potentiate the risk of ventricular arrhythmias including ventricular tachycardia, ventricular fibrillation, and torsade de pointes. The risk appears to be greatest with grepafloxacin and sparfloxacin (both are no longer marketed in the U.S.), although cardiovascular morbidity and mortality attributable to QT prolongation have also been reported rarely with others like gatifloxacin, levofloxacin, ciprofloxacin, and ofloxacin. Reported cases have primarily occurred in patients with advanced age, cardiac disease, electrolyte disturbances, and/or underlying medical problems for which they were receiving concomitant medications known to prolong the QT interval. Therapy with quinolones should be avoided in patients with known QT prolongation and/or uncorrected electrolyte disorders (hypokalemia or hypomagnesemia) and in patients treated concomitantly with class IA or III antiarrhythmic agents. Cautious use with ECG monitoring is advised in patients with other proarrhythmic conditions such as clinically significant bradycardia, congestive heart failure, acute myocardial ischemia, and atrial fibrillation. As QT prolongation may be a concentration-dependent effect, it is important that the recommended dosages or infusion rates of these drugs not be exceeded, particularly in patients with renal and/or hepatic impairment.

  29 sources

  1. Jaillon P, Morganroth J, Brumpt I, Talbot G "Overview of electrocardiographic and cardiovascular safety data for sparfloxacin. Sparfloxacin Safety Group." J Antimicrob Chemother 37(suppl a) (1996): 161-7
  2. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):
  3. "Product Information. Zagam (sparfloxacin)." Rhone Poulenc Rorer (2001):
  4. Demolis JL, Charransol A, Funck-Brentano C, Jaillon P "Effects of a single oral dose of sparfloxacin on ventricular repolarization in healthy volunteers." Br J Clin Pharmacol 41 (1996): 499-503
  5. Dupont H, Timsit JF, Souweine B, Gachot B, Wolff M, Regnier B "Torsades de pointe probably related to sparfloxacin." Eur J Clin Microbiol Infect Dis 15 (1996): 350-1
  6. Morganroth J, Hunt T, Dorr MB, Magner D, Talbot GH "The cardiac pharmacodynamics of therapeutic doses of sparfloxacin." Clin Ther 21 (1999): 1171-81
  7. Samaha FF "QTC interval prolongation and polymorphic ventricular tachycardia in association with levofloxacin." Am J Med 107 (1999): 528-9
  8. "Product Information. Avelox (moxifloxacin)." Bayer (2001):

  Show all 29 sourcesShow fewer sources

  9. "Product Information. Tequin (gatifloxacin)." Bristol-Myers Squibb (2001):
  10. Siepmann M, Kirch W "Drug points - Tachycardia associated with moxifloxacin." Br Med J 322 (2001): 23
  11. Owens RC "Risk assessment for antimicrobial agent-induced QTc interval prolongation and torsades de pointes." Pharmacotherapy 21 (2001): 301-19
  12. Iannini PB, Circiumaru I "Gatifloxacin-induced QTc prolongation and ventricular tachycardia." Pharmacotherapy 21 (2001): 361-2
  13. Demolis JL, Kubitza D, Tenneze L, Funck-Bretano C "Effect of a single oral dose of moxifloxacin (400 mg and 800 mg) on ventricular repolarization in healthy subjects." Clin Pharmacol Ther 68 (2000): 658-66
  14. Iannini PB, Doddamani S, Byazrova E, Curciumaru I, Kramer H "Risk of torsades de pointes with non-cardiac drugs." BMJ 322 (2001): 46-7
  15. Kang J, Wang L, Chen XL, Triggle DJ, Rampe D "Interactions of a series of fluoroquinolone antibacterial drugs with the human cardiac K+ channel HERG." Mol Pharmacol 59 (2001): 122-6
  16. Kahn JB "Latest industry information on the safety profile of levofloxacin in the US." Chemotherapy 47 Suppl 3 (2001): 32-7
  17. Frothingham R "Rates of torsades de pointes associated with ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin, and moxifloxacin." Pharmacotherapy 21 (2001): 1468-72
  18. Bertino JS Jr, Owens RC Jr, Carnes TD, Iannini PB "Gatifloxacin-associated corrected QT interval prolongation, torsades de pointes, and ventricular fibrillation in patients with known risk factors." Clin Infect Dis 34 (2002): 861-3
  19. Oliphant CM, Green GM "Quinolones: a comprehensive review." Am Fam Physician 65 (2002): 455-64
  20. Owens RC Jr, Ambrose PG "Torsades de pointes associated with fluoroquinolones." Pharmacotherapy 22 (2002): 663-8; discussion 668-72
  21. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  22. Noel GJ, Natarajan J, Chien S, Hunt TL, Goodman DB, Abels R "Effects of three fluoroquinolones on QT interval in healthy adults after single doses." Clin Pharmacol Ther 73 (2003): 292-303
  23. Ansari SR, Chopra N "Gatifloxacin and Prolonged QT Interval." Am J Med Sci 327 (2004): 55-6
  24. Iannini PB "Cardiotoxicity of macrolides, ketolides and fluoroquinolones that prolong the QTc interval." Expert Opin Drug Saf 1 (2002): 121-8
  25. Noel GJ, Goodman DB, Chien S, Solanki B, Padmanabhan M, Natarajan J "Measuring the Effects of Supratherapeutic Doses of Levofloxacin on Healthy Volunteers Using Four Methods of QT Correction and Periodic and Continuous ECG Recordings." J Clin Pharmacol 44 (2004): 464-73
  26. Owens RC "QT Prolongation with Antimicrobial Agents : Understanding the Significance." Drugs 64 (2004): 1091-124
  27. Daya SK, Gowda RM, Khan IA "Ciprofloxacin- and hypocalcemia-induced torsade de pointes triggered by hemodialysis." Am J Ther 11 (2004): 77-9
  28. Katritsis D, Camm AJ "Quinolones: cardioprotective or cardiotoxic." Pacing Clin Electrophysiol 26 (2003): 2317-20
  29. Stahlmann R "Clinical toxicological aspects of fluoroquinolones." Toxicol Lett 127 (2002): 269-77

• Myasthenia Gravis

  Major

  Fluoroquinolones have neuromuscular blocking activity and may exacerbate muscle weakness in persons with myasthenia gravis. Postmarketing serious adverse events, including deaths and requirement for ventilatory support, have been associated with fluoroquinolones use in persons with myasthenia gravis. Fluoroquinolones should be avoided in patients with history of myasthenia gravis.

  7 sources

  1. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  2. "Product Information. Noroxin (norfloxacin)." Merck & Co., Inc (2001):
  3. "Product Information. Floxin (ofloxacin)." Ortho McNeil Pharmaceutical (2001):
  4. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):
  5. "Product Information. Raxar (grepafloxacin)." Glaxo Wellcome (2001):
  6. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  7. "Product Information. Baxdela (delafloxacin)." Melinta Therapeutics, Inc. (2017):

• Peripheral Nervous System Diseases

  Major

  The use of quinolones has been associated with an increased risk of peripheral neuropathy. Monitor closely and discontinue their use in patients experiencing symptoms of peripheral neuropathy. It is recommended to avoid these agents in patients who have previously experienced peripheral neuropathy.

  14 sources

  1. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  2. "Product Information. Penetrex (enoxacin)." Rhone Poulenc Rorer (2002):
  3. "Product Information. Maxaquin (lomefloxacin)." Searle (2002):
  4. "Product Information. Neggram (nalidixic acid)." Sanofi Winthrop Pharmaceuticals
  5. "Product Information. Noroxin (norfloxacin)." Merck & Co., Inc (2001):
  6. "Product Information. Floxin (ofloxacin)." Ortho McNeil Pharmaceutical (2001):
  7. "Product Information. Cinobac (cinoxacin)." Oclassen Pharmaceuticals Inc (2001):
  8. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):

  Show all 14 sourcesShow fewer sources

  9. "Product Information. Zagam (sparfloxacin)." Rhone Poulenc Rorer (2001):
  10. "Product Information. Trovan (trovafloxacin)." Pfizer U.S. Pharmaceuticals (2001):
  11. "Product Information. Avelox (moxifloxacin)." Bayer (2001):
  12. "Product Information. Tequin (gatifloxacin)." Bristol-Myers Squibb (2001):
  13. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  14. "Product Information. Baxdela (delafloxacin)." Melinta Therapeutics, Inc. (2017):

• Tendinopathy

  Major

  Tendonitis and ruptures of the shoulder, hand, and Achilles tendons have been reported in patients receiving quinolones, both during and after treatment. Avoid the use of these agents in patients who have a history of tendon disorders or have experienced tendinitis or tendon rupture. Therapy with quinolones should be administered cautiously in patients with patients with kidney, heart, and lung transplant, since it may delay the recognition or confound the diagnosis of a quinolone-induced musculoskeletal effect. Factors that may independently increase the risk of tendon rupture include strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis. It is recommended to discontinue these agents if, at any time during therapy, pain, inflammation or rupture of a tendon develops and institute appropriate treatment.

  19 sources

  1. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  2. "Product Information. Penetrex (enoxacin)." Rhone Poulenc Rorer (2002):
  3. "Product Information. Maxaquin (lomefloxacin)." Searle (2002):
  4. "Product Information. Neggram (nalidixic acid)." Sanofi Winthrop Pharmaceuticals
  5. "Product Information. Noroxin (norfloxacin)." Merck & Co., Inc (2001):
  6. "Product Information. Floxin (ofloxacin)." Ortho McNeil Pharmaceutical (2001):
  7. "Product Information. Cinobac (cinoxacin)." Oclassen Pharmaceuticals Inc (2001):
  8. Donck JB, Segaert MF, Vanrenterghem YF "Fluoroquinolones and achilles tendinopathy in renal transplant recipients." Transplantation 58 (1994): 736-7

  Show all 19 sourcesShow fewer sources

  9. Schacht P, Arcieri G, Hullmann R "Safety of oral ciprofloxacin. An update based on clinical trial results." Am J Med 87 (1989): s98-102
  10. Zabraniecki L, Negrier I, Vergne P, Arnaud M, Bonnet C, Bertin P, Treves R "Fluoroquinolone induced tendinopathy: report of 6 cases." J Rheumatol 23 (1996): 516-20
  11. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):
  12. Carrasco JM, Garcia B, Andujar C, Garrote F, de Juana P, Bermejo T "Tendinitis associated with ciprofloxacin." Ann Pharmacother 31 (1997): 120
  13. "Product Information. Zagam (sparfloxacin)." Rhone Poulenc Rorer (2001):
  14. "Product Information. Trovan (trovafloxacin)." Pfizer U.S. Pharmaceuticals (2001):
  15. "Product Information. Avelox (moxifloxacin)." Bayer (2001):
  16. "Product Information. Tequin (gatifloxacin)." Bristol-Myers Squibb (2001):
  17. Casparian JM, Luchi M, Moffat RE, Hinthorn D "Quinolones and tendon ruptures." South Med J 93 (2000): 392-6
  18. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  19. "Product Information. Baxdela (delafloxacin)." Melinta Therapeutics, Inc. (2017):

• Crystalluria

  Moderate

  Crystalluria has been reported rarely during quinolone therapy. Although it is not expected to occur under normal circumstances with usual recommended dosages, patients who are dehydrated (e.g., due to severe diarrhea or vomiting) may be at increased risk and should be encouraged to consume additional amounts of liquid or given intravenous fluid to ensure an adequate urinary output. Alkalinity of the urine should be avoided, since it may also increase the risk of crystalluria. Renal function tests should be performed periodically during prolonged therapy (> 2 weeks).

  16 sources

  1. Thorsteinsson SB, Bergan T, Oddsdottir S, Rohwedder R, Holm R "Crystalluria and ciprofloxacin, influence of urinary pH and hydration." Chemotherapy 32 (1986): 408-17
  2. Ball P "Ciprofloxacin: an overview of adverse experiences." J Antimicrob Chemother 18 (1986): 187-93
  3. "Product Information. Cipro (ciprofloxacin)." Bayer (2002):
  4. "Product Information. Penetrex (enoxacin)." Rhone Poulenc Rorer (2002):
  5. "Product Information. Maxaquin (lomefloxacin)." Searle (2002):
  6. "Product Information. Neggram (nalidixic acid)." Sanofi Winthrop Pharmaceuticals
  7. "Product Information. Noroxin (norfloxacin)." Merck & Co., Inc (2001):
  8. "Product Information. Floxin (ofloxacin)." Ortho McNeil Pharmaceutical (2001):

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  9. "Product Information. Cinobac (cinoxacin)." Oclassen Pharmaceuticals Inc (2001):
  10. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):
  11. "Product Information. Zagam (sparfloxacin)." Rhone Poulenc Rorer (2001):
  12. "Product Information. Trovan (trovafloxacin)." Pfizer U.S. Pharmaceuticals (2001):
  13. "Product Information. Avelox (moxifloxacin)." Bayer (2001):
  14. "Product Information. Tequin (gatifloxacin)." Bristol-Myers Squibb (2001):
  15. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  16. Stratta P, Lazzarich E, Canavese C, Bozzola C, Monga G "Ciprofloxacin crystal nephropathy." Am J Kidney Dis 50 (2007): 330-5

• Diabetes Mellitus

  Moderate

  The use of certain quinolones has been associated with disturbances in blood glucose homeostasis possibly stemming from effects on pancreatic beta cell ATP-sensitive potassium channels that regulate insulin secretion. Hypoglycemia and, less frequently, hyperglycemia have been reported, although the latter may also occur due to infection alone. Hypoglycemia has usually occurred in patients with diabetes receiving concomitant oral hypoglycemic agents and/or insulin. Administration of ciprofloxacin, levofloxacin, norfloxacin, and especially gatifloxacin in patients treated with sulfonylureas or other oral hypoglycemic agents has resulted in severe, refractory hypoglycemia and hypoglycemic coma. Elderly patients and patients with reduced renal function are particularly susceptible. Blood glucose should be monitored more closely whenever quinolones are prescribed to patients with diabetes. Gatifloxacin has been known to cause hypoglycemic episodes generally within the first 3 days of therapy and sometimes even after the first dose, while hyperglycemia usually occurs 4 to 10 days after initiation of therapy. Patients should be counseled to recognize symptoms of hypoglycemia such as headache, dizziness, drowsiness, nausea, tremor, weakness, hunger, excessive perspiration, and palpitations. If hypo- or hyperglycemia occur during quinolone therapy, patients should initiate appropriate remedial therapy immediately, discontinue the antibiotic, and contact their physician.

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  2. "Product Information. Noroxin (norfloxacin)." Merck & Co., Inc (2001):
  3. "Product Information. Floxin (ofloxacin)." Ortho McNeil Pharmaceutical (2001):
  4. "Product Information. Levaquin (levofloxacin)." Ortho McNeil Pharmaceutical (2001):
  5. "Product Information. Raxar (grepafloxacin)." Glaxo Wellcome (2001):
  6. "Product Information. Trovan (trovafloxacin)." Pfizer U.S. Pharmaceuticals (2001):
  7. Gajjar DA, LaCreta FP, Kollia GD, et al. "Effect of multiple-dose gatifloxacin or ciprofloxacin on glucose homeostasis and insulin production in patients with noninsulin-dependent diabetes mellitus maintained with diet and exercise." Pharmacotherapy 20 (6 Pt 2) (2000): s76-86
  8. Roberge RJ, Kaplan R, Frank R, Fore C "Glyburide-ciprofloxacin interaction with resistant hypoglycemia." Ann Emerg Med 36 (2000): 160-3

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  9. Rubinstein E "History of quinolones and their side effects." Chemotherapy 47 Suppl 3 (2001): 3-8
  10. Menzies DJ, Dorsainvil PA, Cunha BA, Johnson DH "Severe and persistent hypoglycemia due to gatifloxacin interaction with oral hypoglycemic agents." Am J Med 113 (2002): 232-4
  11. Baker SE, Hangii MC "Possible gatifloxacin-induced hypoglycemia." Ann Pharmacother 36 (2002): 1722-6
  12. "Product Information. Factive (gemifloxacin)." *GeneSoft Inc (2003):
  13. "Hypoglycemia and hyperglycemia with fluoroquinolones." Med Lett Drugs Ther 45 (2003): 64
  14. Donaldson AR, Vandiver JR, Finch CK "Possible gatifloxacin-induced hyperglycemia." Ann Pharmacother 38 (2004): 602-5
  15. LeBlanc M, Belanger C, Cossette P "Severe and resistant hypoglycemia associated with concomitant gatifloxacin and glyburide therapy." Pharmacotherapy 24 (2004): 926-31
  16. Biggs WS "Hypoglycemia and hyperglycemia associated with gatifloxacin use in elderly patients." J Am Board Fam Pract 16 (2004): 455-7
  17. Gavin JR 3rd, Kubin R, Choudhri S, et al. "Moxifloxacin and glucose homeostasis: a pooled-analysis of the evidence from clinical and postmarketing studies." Drug Saf 27 (2004): 671-86
  18. Saraya A, Yokokura M, Gonoi T, Seino S "Effects of fluoroquinolones on insulin secretion and beta-cell ATP-sensitive K(+) channels." Eur J Pharmacol 497 (2004): 111-7
  19. Lin G, Hays DP, Spillane L "Refractory hypoglycemia from ciprofloxacin and glyburide interaction." J Toxicol Clin Toxicol 42 (2004): 295-7
  20. Friedrich LV, Dougherty R "Fatal hypoglycemia associated with levofloxacin." Pharmacotherapy 24 (2004): 1807-12
  21. Bhasin R, Arce FC, Pasmantier R "Hypoglycemia associated with the use of gatifloxacin." Am J Med Sci 330 (2005): 250-3
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  23. Park-Wyllie LY, Juurlink DN, Kopp A, et al. "Outpatient gatifloxacin therapy and dysglycemia in older adults." N Engl J Med 354 (2006): 1352-61
  24. Wang S, Rizvi AA "Levofloxacin-induced hypoglycemia in a nondiabetic patient." Am J Med Sci 331 (2006): 334-5
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  27. "Product Information. Baxdela (delafloxacin)." Melinta Therapeutics, Inc. (2017):

• Diseases requiring hemodialysis

  Moderate

  The following quinolones are known to be partially removed by hemodialysis and should be administered after dialysis: ciprofloxacin, enoxacin, gatifloxacin, levofloxacin, lomefloxacin, and ofloxacin.

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  2. Kampf D, Borner K, Pustelnik A "Multiple dose kinetics of ofloxacin and ofloxacin metabolites in haemodialysis patients." Eur J Clin Pharmacol 42 (1992): 95-9
  3. Lameire N, Rosenkranz B, Malerczyk V, Lehr KH, Veys N, Ringoir S "Ofloxacin pharamcokinetics in chronic renal failure and dialysis." Clin Pharmacokinet 21 (1991): 357-71
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  8. "Product Information. Maxaquin (lomefloxacin)." Searle (2002):

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  12. Thalhammer F, Kletzmayr J, ElMenyawi I, Kovarik J, Rosenkranz AR, Traunmuller F, Horl WH, Burgmann H "Ofloxacin clearance during hemodialysis: A comparison of polysulfone and cellulose acetate hemodialyzers." Am J Kidney Dis 32 (1998): 642-5
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• Kidney Diseases

  Moderate

  Quinolones (except trovafloxacin, moxifloxacin, and nalidixic acid) and their metabolites are eliminated by the kidney. Patients with renal impairment may be at greater risk for adverse effects from quinolones, including nephrotoxicity, due to decreased drug clearance. Dosage adjustments may be necessary and modifications should be based on the degree of renal impairment and severity of infection in accordance with the individual product package labeling. Renal function tests should be performed periodically during therapy.

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  11. Simpson J, Watson AR, Mellersh A, Nelson CS, Dodd K "Typhoid fever, ciprofloxacin, and renal failure." Arch Dis Child 66 (1991): 1083-4
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  20. Nilsen OG, Saltvedt E, Walstad RA, Marstein S "Single-dose pharmacokinetics of lomefloxacin in patients with normal and impaired renal function." Am J Med 92 (1992): s38-40
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  49. "Product Information. Tequin (gatifloxacin)." Bristol-Myers Squibb (2001):
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