Can ciprofloxacin (Cipro) cause hemolysis in patients with Glucose-6-phosphate dehydrogenase (G6PD) deficiency, and is G6PD deficiency common in Bihar?

Ciprofloxacin and G6PD Deficiency: Safety and Prevalence in Bihar

Ciprofloxacin can be safely prescribed to patients with G6PD deficiency as it has not been shown to cause hemolysis in these patients. Recent real-world evidence demonstrates that ciprofloxacin has been safely prescribed to hundreds of G6PD-deficient patients without causing hemolytic episodes 1.

Safety of Ciprofloxacin in G6PD Deficiency

• A comprehensive 2024 real-world study examining 31,962 G6PD-deficient patients found that ciprofloxacin was safely prescribed to hundreds of patients without causing hemolytic episodes 1.
• This study identified only 71 cases (0.2%) of major hemolysis requiring hospitalization in the entire cohort, with the vast majority (71.8%) caused by fava beans, not medications 1.
• Among medications that caused hemolysis, ciprofloxacin was not implicated, while nitrofurantoin, phenazopyridine, and an unspecified "pain killer" were the only medications associated with hemolytic episodes 1.

Medications to Avoid in G6PD Deficiency

According to evidence-based reviews, only seven medications have solid evidence showing they should be avoided in G6PD-deficient patients 2:

1. Dapsone
2. Methylthioninium chloride (methylene blue)
3. Nitrofurantoin
4. Phenazopyridine
5. Primaquine
6. Rasburicase
7. Tolonium chloride (toluidine blue)

Notably, ciprofloxacin is not on this list of prohibited medications.

G6PD Deficiency Screening Recommendations

Clinical guidelines recommend:

• Qualitative screening for G6PD deficiency upon entry into care or before starting therapy with an oxidant drug in patients with predisposing racial or ethnic backgrounds 3.
• The most common variants are:
  • GdA-, found in 10-15% of Black men and women
  • Gdmed, found predominantly in men from the Mediterranean, India, and Southeast Asia 3

Prevalence of G6PD Deficiency in Bihar

While the guidelines don't specifically mention prevalence rates in Bihar, they do indicate that the Gdmed variant is common in men from India 3. This variant is associated with more severe, potentially life-threatening hemolysis compared to the GdA- variant, which causes milder, self-limited hemolysis 3.

Clinical Implications

• When prescribing medications to patients from areas with high G6PD deficiency prevalence (including parts of India), screening for G6PD deficiency is recommended before starting oxidant drugs 3.
• However, ciprofloxacin is not classified as an oxidant drug that requires G6PD screening prior to administration 2, 1.
• For patients with known G6PD deficiency, ciprofloxacin can be prescribed at normal therapeutic doses without concerns for hemolysis 1.

Conclusion

Ciprofloxacin does not cause hemolysis in G6PD-deficient patients and can be safely prescribed. While G6PD deficiency is present in India, including the Gdmed variant which can cause severe hemolysis with certain medications, ciprofloxacin is not among the medications that pose a risk to these patients.