Risks Associated with Ciprofloxacin
Ciprofloxacin carries significant risks including tendinopathy, tendon rupture, peripheral neuropathy, CNS effects, QT prolongation, and hypersensitivity reactions, with special caution needed in elderly patients, those with renal impairment, and those taking corticosteroids. 1
Musculoskeletal Risks
- Tendinitis and tendon rupture are among the most serious adverse effects, with the Achilles tendon most frequently involved, potentially requiring surgical repair 1
- Risk factors for tendon complications include:
- Tendon rupture can occur during treatment or even several months after completing therapy 1
- In pediatric patients, arthropathy has been reported at rates of 9.3% compared to 6.0% in control patients 2, 3
Neurological Risks
- Peripheral neuropathy with symptoms including pain, burning, tingling, numbness, and weakness in arms, hands, legs, or feet 1
- Central nervous system effects include:
- Increased intracranial pressure and toxic psychosis have been reported 1
- CNS side effects may occur after taking just the first dose 1
Cardiovascular Risks
- QT interval prolongation that may lead to potentially fatal dysrhythmias (torsade de pointes) 2, 1
- Higher risk in patients with:
Gastrointestinal Risks
- Most common adverse effects (2-8% of patients) include nausea, vomiting, diarrhea, and abdominal discomfort 5
- Risk of Pseudomembranous colitis (Clostridioides difficile-associated diarrhea) 1
- Symptoms may include watery or bloody diarrhea, stomach cramps, and fever 1
- Can occur up to 2 months after finishing antibiotic treatment 1
Hypersensitivity Reactions
- Severe allergic reactions can occur even after only one dose 1
- Symptoms include hives, trouble breathing or swallowing, swelling of lips/tongue/face, throat tightness, rapid heartbeat, and fainting 1
- Skin rash may be a sign of a more serious reaction 1
Drug Interactions
- Ciprofloxacin inhibits the CYP1A2 enzyme pathway, leading to potentially dangerous interactions with medications like theophylline and tizanidine 2, 1
- Absorption is inhibited by foods or supplements containing multivalent cations (magnesium, aluminum, iron, calcium) 2
Special Populations
Elderly Patients
- No specific increased frequency of adverse effects has been reported in the elderly, but large comparative trials are lacking 4
- Dosage adjustments should be considered due to age-related decline in renal function 4
- Elderly patients (over 60) have increased risk of tendon disorders 4
Pediatric Patients
- Should be used in pediatric patients only for specific indicated infections with careful consideration of risks 3
- Fluoroquinolones cause arthropathy in juvenile animals, which was the original basis for limiting their use in pediatric patients 3
- Most reported musculoskeletal events in children were of moderate intensity and transient in nature 3
Pregnant Women
- Safety and effectiveness in pregnant and lactating women have not been established 1
Risk Mitigation
- Discontinue ciprofloxacin at first sign of tendon pain, swelling, inflammation or rupture 1
- Avoid use in patients with risk factors for tendon complications when possible 2
- Monitor for signs of peripheral neuropathy 1
- Use with caution in patients with known or suspected CNS disorders that may predispose to seizures 1
- Avoid in patients with known QT interval prolongation, uncorrected electrolyte abnormalities, or those taking Class IA or III antiarrhythmic agents 4
- Discontinue immediately if hypersensitivity reactions occur 1