Which is safer for patients with Glucose-6-phosphate dehydrogenase (G6PD) deficiency in Bihar, nitrofurantoin or ciprofloxacin, in terms of causing hemolysis?

Ciprofloxacin is Safer than Nitrofurantoin for G6PD Deficient Patients in Bihar

Ciprofloxacin should be used instead of nitrofurantoin in patients with G6PD deficiency in Bihar due to the significantly lower risk of hemolysis. 1, 2, 3

Evidence on Medication Safety in G6PD Deficiency

Nitrofurantoin

• Nitrofurantoin is explicitly contraindicated in G6PD deficiency according to multiple sources:
  • The FDA label specifically warns: "Cases of hemolytic anemia of the primaquine-sensitivity type have been induced by nitrofurantoin. Hemolysis appears to be linked to a glucose-6-phosphate dehydrogenase deficiency in the red blood cells of the affected patients." 1
  • It is one of only seven medications with solid evidence to prohibit use in G6PD deficient patients 2
  • Hemolysis is an indication for discontinuing nitrofurantoin; hemolysis ceases when the drug is withdrawn 1

Ciprofloxacin

• Ciprofloxacin has been prescribed safely to hundreds/thousands of G6PD-deficient patients without causing major hemolysis 3
• A 2017 study specifically found fluoroquinolones (including ciprofloxacin) to be safe in G6PD deficient patients, with no episodes of acute hemolytic anemia observed 4
• Fluoroquinolones are not listed among medications that should be avoided in G6PD deficiency 2

G6PD Deficiency in Bihar

G6PD deficiency is prevalent in Bihar, which is part of the Indian subcontinent. The Mediterranean variant (Gdmed) is commonly found in individuals from India and has a very high risk of severe hemolysis when exposed to oxidant drugs 5. This variant can cause life-threatening hemolysis, unlike the milder GdA variant found in African populations.

Risk Assessment

Nitrofurantoin Risk

• High risk of hemolysis in G6PD deficient patients
• Listed as one of the seven medications absolutely contraindicated in G6PD deficiency 2
• Recent real-world data (2024) identified a case of major hemolysis requiring hospitalization associated with nitrofurantoin use in a G6PD deficient patient 3

Ciprofloxacin Risk

• Low risk of hemolysis in G6PD deficient patients
• Has been safely prescribed to hundreds/thousands of G6PD deficient patients 3
• No episodes of acute hemolytic anemia observed in a study of fluoroquinolone prophylaxis in G6PD deficient patients 4

Management Algorithm for Urinary Tract Infections in G6PD Deficient Patients

1. Screen for G6PD deficiency before prescribing antimicrobials in populations with high prevalence, such as Bihar 5

2. If G6PD deficiency is confirmed or suspected:

   • First choice: Ciprofloxacin (safer option)
   • Avoid: Nitrofurantoin (contraindicated)

3. If G6PD status is unknown and testing is unavailable:

   • Choose ciprofloxacin as the safer option
   • Monitor for signs of hemolysis (jaundice, pallor, dark urine, fatigue)

4. If hemolysis occurs:

   • Immediately discontinue the offending medication
   • Provide supportive care including hydration
   • Monitor hemoglobin levels
   • Consider transfusion for severe cases

Conclusion

Based on the available evidence, ciprofloxacin is clearly the safer choice for treating urinary tract infections in patients with G6PD deficiency in Bihar. Nitrofurantoin carries a significant risk of hemolysis in these patients and should be avoided.