What are the side effects of Ciprofloxacin (ciprofloxacin)?

Ciprofloxacin Side Effects

Ciprofloxacin has numerous potential side effects ranging from common gastrointestinal disturbances to serious adverse events including tendon rupture, peripheral neuropathy, and QT prolongation that can significantly impact morbidity and mortality. 1, 2

Common Side Effects

Gastrointestinal

• Nausea
• Vomiting
• Diarrhea
• Abdominal pain
• Dyspepsia 1

Dermatological

• Rash
• Photosensitivity (can cause severe sunburn, blisters or swelling) 1, 2

Administration-related

• Injection and infusion site reactions (only with intravenous administration) 1

Serious Side Effects

Musculoskeletal

• Tendinitis and tendon rupture (particularly Achilles tendon)
  • Higher risk in:
    • Older patients (especially over 60)
    • Patients taking corticosteroids
    • Patients with kidney, heart or lung transplants
    • Those with renal failure
    • Those with previous tendon disorders 2

Neurological

• Peripheral neuropathy (can be permanent)
  • Symptoms include pain, burning, tingling, numbness, and weakness in arms, hands, legs, or feet 2
• Central nervous system effects:
  • Dizziness
  • Seizures
  • Hallucinations
  • Confusion
  • Depression
  • Insomnia
  • Anxiety
  • Tremors 2

Cardiovascular

• QT interval prolongation (rare but serious)
  • Higher risk in:
    • Elderly patients
    • Those with family history of prolonged QT interval
    • Patients with hypokalemia
    • Those taking antiarrhythmic medications 1, 2

Immunological

• Severe allergic reactions (can occur after first dose)
  • Hives
  • Difficulty breathing or swallowing
  • Facial swelling
  • Throat tightness
  • Rapid heartbeat 2

Gastrointestinal (Serious)

• Pseudomembranous colitis (can occur up to 2 months after treatment)
  • Symptoms: watery or bloody diarrhea, stomach cramps, fever 1, 2

Metabolic

• Hypoglycemia (especially in diabetic patients taking oral antidiabetic medications) 1, 2

Hepatic

• Liver problems (rare)
  • Signs include yellowing of skin/eyes, dark urine 2

Monitoring Recommendations

• ECG monitoring: Baseline, 2 weeks into treatment, and after adding any medication known to prolong QT interval 1
• Blood glucose: Regular monitoring in patients with diabetes 1
• Routine laboratory monitoring: Periodic FBC, U&Es, LFTs throughout treatment 1

Special Populations

Pregnant Women

• Limited human clinical data
• Use only when benefits outweigh risks
• First-line agent for anthrax exposure during pregnancy 1

Children

• Not generally recommended for children under 18 years due to risk of arthropathy
• May be considered for specific infections when benefits outweigh risks 1

Drug Interactions

Ciprofloxacin has numerous important drug interactions:

• Absorption reduced by:

  • Antacids, calcium, iron, magnesium, aluminum-containing products (take ciprofloxacin 1-2 hours before or 4 hours after) 1
  • Dairy products or mineral-fortified drinks 1

• Increased risk with:

  • Anticoagulants (enhanced effect of warfarin)
  • QT-prolonging medications (antiarrhythmics, tricyclic antidepressants, macrolides)
  • Theophylline (increased serum levels, risk of seizures)
  • Methotrexate (increased risk of toxicity)
  • Tizanidine (increased serum concentrations)
  • NSAIDs (may increase risk of CNS stimulation and seizures) 1

Risk Mitigation Strategies

1. For tendon damage risk: Stop ciprofloxacin at first sign of tendon pain, swelling, or inflammation and rest affected area 2

2. For photosensitivity: Avoid sunlamps and tanning beds; use sunscreen and protective clothing when outdoors 2

3. For peripheral neuropathy: Discontinue at first signs of nerve symptoms to prevent permanent damage 2

4. For drug interactions: Carefully time administration with other medications, especially those containing divalent cations 1

5. For QT prolongation: Avoid in patients with known QT prolongation or those taking other QT-prolonging medications 1

Key Pitfalls to Avoid

• Don't ignore early warning signs of tendon pain or neurological symptoms as these can progress to permanent damage 2, 3
• Don't prescribe with theophylline without careful monitoring due to serious and potentially fatal interactions 2
• Don't continue medication if patient develops rash, as this may be an early sign of a serious skin reaction 2
• Don't administer with dairy products or mineral supplements as this significantly reduces absorption 1
• Don't underestimate the risk of peripheral neuropathy, which can be permanent and debilitating even after short-term use 4, 3

By understanding these side effects and taking appropriate precautions, healthcare providers can minimize the risks associated with ciprofloxacin therapy while maintaining its effectiveness for appropriate indications.