Do moxifloxacin, bedaquiline, linezolid, delamanid, and cycloserine cause hyperglycemia?

Hyperglycemia Risk with Moxifloxacin, Bedaquiline, Linezolid, Delamanid, and Cycloserine

Based on current guidelines, linezolid and fluoroquinolones (including moxifloxacin) are associated with dysglycemia, while there is no strong evidence linking bedaquiline, delamanid, or cycloserine directly to hyperglycemia. 1

Evidence for Each Medication

Moxifloxacin

• Fluoroquinolones, including moxifloxacin, are listed in WHO and ATS/CDC/ERS/IDSA guidelines as medications that can cause dysglycemia 1
• However, comprehensive analysis of clinical trials and post-marketing data for moxifloxacin specifically showed no clinically relevant effect on blood glucose homeostasis, with hyperglycemic events occurring in <0.1% of patients 2
• Moxifloxacin appears to have a more favorable glycemic profile compared to other fluoroquinolones like gatifloxacin, which has been documented to cause severe hyperglycemia 3

Bedaquiline

• Current TB treatment guidelines do not list hyperglycemia as a significant adverse effect of bedaquiline 1
• The main documented adverse effects of bedaquiline are QT interval prolongation and hepatotoxicity, rather than metabolic disturbances 1

Linezolid

• Linezolid is specifically listed in TB treatment guidelines as a medication associated with dysglycemia 1
• Case reports document linezolid-induced hypoglycemia, particularly in diabetic patients and those on extended therapy 4, 5
• Hypoglycemia risk appears to be related to linezolid's monoamine oxidase (MAO) inhibitory properties 5

Delamanid

• Current TB treatment guidelines do not list hyperglycemia as a known adverse effect of delamanid 1
• The primary safety concern with delamanid is QT interval prolongation, especially when combined with other QT-prolonging drugs 1

Cycloserine

• TB treatment guidelines do not specifically associate cycloserine with hyperglycemia 1
• The main documented adverse effects of cycloserine are mental health changes and peripheral neuropathy 1

Monitoring Recommendations

• Monitor blood glucose levels in patients receiving MDR-TB regimens containing linezolid or fluoroquinolones, particularly in:

  • Patients with pre-existing diabetes 1
  • Elderly patients 1, 5
  • Patients with renal impairment 5, 3
  • Patients taking multiple medications that may affect glucose metabolism 1

• For patients on linezolid, consider:

  • Periodic monitoring of blood glucose, especially during extended therapy 4
  • Being alert for signs of hypoglycemia, which may be more common than hyperglycemia 4, 5

• For patients on fluoroquinolones (including moxifloxacin):

  • Monitor for symptoms of hyperglycemia (polydipsia, polyphagia, polyuria) 1
  • Consider routine fasting blood glucose measurements during treatment 1

Clinical Implications

• When designing MDR-TB regimens, be aware that:

  • Linezolid has been associated with both hypoglycemia and lactic acidosis 4, 5
  • The combination of multiple drugs with potential metabolic effects may increase the risk of dysglycemia 1
  • The benefits of these medications in treating MDR-TB generally outweigh the glycemic risks 1

• For patients who develop hyperglycemia:

  • Consider temporary dose reduction or medication substitution if clinically appropriate 1
  • Manage hyperglycemia according to standard protocols for diabetes care 1
  • Do not abruptly discontinue TB medications without appropriate alternatives in place 6

In conclusion, while linezolid and fluoroquinolones (including moxifloxacin) have documented associations with dysglycemia, there is limited evidence directly linking bedaquiline, delamanid, or cycloserine to hyperglycemia. Careful monitoring of blood glucose is recommended, particularly in high-risk patients receiving MDR-TB treatment regimens.