Quinolones

[EngMac]

This topic has been posted before however I do not remember seeing collagen mentioned. I suspect collagen is important to the spine and changes or lack of replacement has an impact on the initiation of atrial fibrillation. When I get time, I will post a better explanation about why I think this.

The Many Perils of Quinolones

The US Food and Drug Administration (FDA) has issued a raft of warnings about this drug class over the past decade, making levofloxacin my choice for the drug to not use in this case.

Tendinopathy. The first of these, issued in July 2008, warned about the risk for tendonitis and tendon rupture. The most common site is the Achilles tendon, though shoulder tendons are also frequently involved. Highest risk is found in patients taking steroids along with a fluoroquinolone as well as in older adults. While this adverse event has been documented in a number of studies, there continue to be lawsuits alleging that affected patients were not informed of this risk.

Peripheral neuropathy. In August 2013, a second warning, this time about the risk for peripheral neuropathy, was issued. This serious adverse effect can be permanent, even in patients taking a fluoroquinolone for as few as 4-5 days.

Long term neurologic risk. In July 2016, the FDA issued a more comprehensive alert, warning that fluoroquinolones should not be prescribed if other alternatives are available for patients with:

Acute sinusitis

Cystitis

Acute bacterial exacerbations of chronic bronchitis

The risks with use of this class of medications outweigh the benefits in patients with these common, relatively mild infections.

Hypoglycemia. Another alert was issued in July 2018, this time regarding the risk for hypoglycemia associated with fluoroquinolones. This is particularly a concern when a fluoroquinolone is prescribed for a patient who is on multiple diabetes medicines.

Aortic aneurysm. The most recent alert was released in December 2018, warning of a rare but potentially fatal aortic aneurysm rupture. This warning followed a number of studies that documented increased risk for collagen-associated effects. A 2015 population-based longitudinal cohort study involving 1.7 million adults 65 years and older tracked those who received a fluoroquinolone prescription.[1] Compared with use of amoxicillin, current use of a fluoroquinolone was associated with a hazard ratio (HR) for tendon ruptures of 3.13; HR for aortic aneurysm was 2.72. Two subsequent studies confirmed this higher risk. A cohort study[2] conducted in Sweden investigated outcomes in almost 400,000 treatment episodes with fluoroquinolones and an equal number of episodes of amoxicillin use. Fluoroquinolone use was associated with an HR of 1.66 for aortic aneurysm or dissection.

A case-crossover study in Taiwan of 1200 patients hospitalized for aortic aneurysm and dissection compared risk during the period in which the patient was exposed to a fluoroquinolone versus a period without that exposure.[3] After controlling for multiple confounders as well as duration of time exposed to a fluoroquinolone, the investigators found that use of a fluoroquinolone within 60 days was associated with the highest risk for aneurysm, with risk increasing with longer durations of exposure. Patients taking a fluoroquinolone for more than 14 days experienced a 2.8-fold increase in risk.

Penicillin Allergy

The older patient described in the brief case above was reported to have a history of suspected penicillin allergy. However, an accumulating body of evidence reassures us that we need not overreact to this history. The most recent study,[4] published in January 2019, was a retrospective review of adult patients with a history of benign rash, somatic symptoms, or an unknown history associated with a penicillin exposure more than 1 year in the past. Patients were directly challenged without preceding skin testing. None had an immediate or delayed hypersensitivity reaction.

A study conducted in 100 children with parent-reported allergy also provides reassurance that low-grade symptoms following exposure to penicillin are unlikely to represent true IgE-mediated allergy.[5] All of the children, ages 3.5 to 18 years, had developed minor symptoms, mostly rash and itching, following a penicillin exposure that occurred more than a year earlier. All were provided with penicillin skin testing.All were negative.

What About Cephalosporins?

Classically, cephalosporins were not prescribed for patients with penicillin allergy due to concerns about cross-reactivity. That concern, too, may be safely put to rest. A retrospective, population-based study involving over 66,000 penicillin-allergic patients (3300 of whom had a previous report of cephalosporin allergy) receiving 127,000 antibiotic courses of cephalosporins identified only three cases of anaphylaxis (none in the cephalosporin-allergic group). This compared with two in the non-penicillin-allergic patients.[6]

The takeaway from these and earlier studies is that clinicians who have the ability to challenge patients with a reported penicillin allergy in a controlled setting, monitor for an hour, and administer epinephrine if required can provide oral challenge in an office setting. Higher-risk patients—those with more serious reported reactions or those who have experienced a suspected reaction within the past year—should be referred to an allergist for skin testing.

Bottom line: Avoiding penicillins and cephalosporins is probably not necessary in these patients, and those two antibiotic classes are much safer for many of the conditions in which a fluoroquinolone is being considered.

[Auriculaire]

The fluoquinolones attack collagen wherever it is found in all connective tissue. This is particularly serious for things like aortic aneurism and retinal detatchment both of which have a significantly higher incidence in patients who have been treated with this class of antibiotics. So far the main arrythmia the drug companies admit they cause is QT prolongation but many floxies report afib and bouts of tachycardia. I read this Medscape article yesterday . The comments are quite disturbing showing that many doctorscare still clinging to prescribing this dangerous class of antibiotic despite the FDA warnings.

[seasider18 in reply to Auriculaire]

Before going for my aortic valve replacement in 2012 I asked the hospital it was OK to go ahead when I had a prostate infection. They said it was alright. In the theatre they were unable to get a catheter in and had to use a supra pubic one. I did not know at the time that they had given me fluoroquinolone. When up and about I found that I had tendonitis and went to my GP wondering how I had got that after a weeks inaction. It cleared up after several weeks of Physio and ultrasound. Twice later my GP prescribed cipro/fluoroquinolone and within a couple of days tendon pain started again and I stopped it but the tendon problem lingered to a degree and I had numbness in my lower left leg and foot when walking. No one could give reason for this. Much later when prescribed Bisoprolol and CLARITHROMYCIN my walking suddenly deteriorated to the stage that I could not walk unaided when outside. A walking stick alone did not help and I had to hold on to my wife's arm and could not go out alone. The change of gait gave me back problems. This is one of the problems for those who were prescribed the drug that it can be dormant for a very long time and be triggered when prescribed other drugs.

I bought an electric wheelchair and later a rollator to be able to get out on my own.

The web site floxiehope.com/ has all the information anyone can need on its affects. The right hand column has links to last years European medicines agency (EMA) London Conference where patients and experts gave evidence of the drugs effects prior to some but not enough restriction being put on them..

[Auriculaire in reply to seasider18]

I gave evidence by email to the EMA enquiry . I think I have been "floxed" 4 times though it is impossible to be 100% sure for the first two in 1989/90 and 1999 as my UK medical records would have been destroyed in 2011 as I had been living in France for 10 years. I did not find out about Fluoroquinolone Toxicity till after my second floxing here in 2015. But I do remember that after being given several courses of antibiotics for chronic sinusitis in 1989/ 90 I developed Achilles tendonitis, excruciating back pain and knee pain. I also had blood sugar problems and generally felt crap . I spent most of the 90s worrying that there was something sinister going on. Gradually I got better and thyroid treatment helped but after the 1999 floxing I developed severe pain in my ribcage. My doc here says I have cartilage degeneration and this happens with old age but I was only 47 when it started. The French floxings brought afib , some mild neuropathy, digestive problems and more tendonitis - rotator cuff both shoulders , behind the knee, hips and elbows and wrists. They come and go but there is always something hurting! I am lucky I can still stand and walk ( not for more than 15/20 mins as then the Achilles start to hurt) and work in my garden. I have the typical cycles with relapses. Often it is hard to know what has caused the relapse. Floxiehope is a great site though I often wonder if the people who post recovery stories after only a few months might not have a return of their symptoms or new ones further down the line. Cipro is an evil gift that keeps on giving. I wish you well and hope that you do see some recovery . I know I keep hoping that I will improve as I did before. I was younger then though and I think that makes a difference. But at least now I know what is wrong with me and I wear a dog tag that says "No Fluoroquinolones".