AUDIENCE: Patient, Health Professional, Pharmacy
ISSUE: FDA is strengthening the current warnings in the prescribing information that fluoroquinolone antibiotics may cause significant decreases in blood sugar and certain mental health side effects.
BACKGROUND: Fluoroquinolone antibiotics are approved to treat certain serious bacterial infections, and have been used for more than 30 years. They work by killing or stopping the growth of bacteria that can cause illness. Without treatment, some infections can spread and lead to serious health problems.
Most fluoroquinolone antibiotic drug labels include a warning that blood sugar disturbances, including high blood sugar and low blood sugar and depending on the fluoroquinolone antibiotic class, a range of mental health side effects are already described under Central Nervous System Effects in the Warnings and Precautions section of the drug label, which differed by individual drug.
RECOMMENDATION: The new label changes will add that low blood sugar levels, also called hypoglycemia, can lead to coma and the new label will also make the mental health side effects more prominent and more consistent across the systemic fluoroquinolone drug class. The mental health side effects to be added to or updated across all the fluoroquinolones are:
- disturbances in attention
- memory impairment
- serious disturbances in mental abilities called delirium.
FDA continues to monitor and evaluate the safety and effectiveness of medicines after we approve them and they go on the market. In the case of fluoroquinolones, we reviewed reports of cases submitted to FDA and the published medical literature of apparently healthy patients who experienced serious changes in mood, behavior, and blood sugar levels while being treated with systemic fluoroquinolones.
Patients should tell your health care professionals if you are taking a diabetes medicine when your health care professional is considering prescribing an antibiotic, and also if you have low blood sugar or symptoms of it while taking a fluoroquinolone. For patients with diabetes, your health care professional may ask you to check your blood sugar more often while taking a fluoroquinolone. Early signs and symptoms of low blood sugar include:
- pounding heart or very fast pulse
- pale skin
- feeling shaky
- unusual hunger
- unusual anxiety
Health care professionals should be aware of the potential risk of hypoglycemia sometimes resulting in coma, occurring more frequently in the elderly and those with diabetes taking an oral hypoglycemic medicine or insulin.
- Alert patients of the symptoms of hypoglycemia and carefully monitor blood glucose levels in these patients, and discuss with them how to treat themselves if they have symptoms of hypoglycemia.
- Inform patients about the risk of psychiatric adverse reactions that can occur after just one dose.
- Stop fluoroquinolone treatment immediately if a patient reports any central nervous system side effects, including psychiatric adverse reactions, or blood glucose disturbances and switch to a non-fluoroquinolone antibiotic if possible.
- Stop fluoroquinolone treatment immediately if a patient reports serious side effects involving the tendons, muscles, joints, or nerves, and switch to a non-fluoroquinolone antibiotic to complete the patient's treatment course.
Health care professionals should not prescribe fluoroquinolones to patients who have other treatment options for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections because the risks outweigh the benefits in these patients.
For more information visit the FDA website at: http://www.fda.gov/Safety/MedWatch/SafetyInformation and http://www.fda.gov/Drugs/DrugSafety.
Using ciprofloxacin injection increases the risk that you will develop tendinitis (swelling of a fibrous tissue that connects a bone to a muscle) or have a tendon rupture (tearing of a fibrous tissue that connects a bone to a muscle) during your treatment or for up to several months afterward. These problems may affect tendons in your shoulder, your hand, the back of your ankle, or in other parts of your body. Tendinitis or tendon rupture may happen to people of any age, but the risk is highest in people over 60 years of age. Tell your doctor if you have or have ever had a kidney, heart, or lung transplant; kidney disease; a joint or tendon disorder such as rheumatoid arthritis (a condition in which the body attacks its own joints, causing pain, swelling, and loss of function); or if you participate in regular physical activity. Tell your doctor and pharmacist if you are taking oral or injectable steroids such as dexamethasone (Decadron, Dexpak), methylprednisolone (Medrol), or prednisone (Sterapred). If you experience any of the following symptoms of tendinitis, stop using ciprofloxacin injection, rest, and call your doctor immediately: pain, swelling, tenderness, stiffness, or difficulty in moving a muscle. If you experience any of the following symptoms of tendon rupture, stop using ciprofloxacin injection and get emergency medical treatment: hearing or feeling a snap or pop in a tendon area, bruising after an injury to a tendon area, or inability to move or bear weight on an affected area.
Using ciprofloxacin injection may cause changes in sensation and nerve damage that may not go away even after you stop using ciprofloxacin. This damage may occur soon after you begin using ciprofloxacin injection. Tell your doctor if you have ever had peripheral neuropathy (a type of nerve damage that causes tingling, numbness, and pain in the hands and feet). If you experience any of the following symptoms, stop using ciprofloxacin and call your doctor immediately: numbness, tingling, pain, burning, or weakness in the arms or legs; or a change in your ability to feel light touch, vibrations, pain, heat, or cold.
Using ciprofloxacin injection may affect your brain or nervous system and cause serious side effects. This can occur after the first dose of ciprofloxacin injection. Tell your doctor if you have or have ever had seizures, epilepsy, cerebral arteriosclerosis (narrowing of blood vessels in or near the brain that can lead to stroke or ministroke), stroke, changed brain structure, or kidney disease. If you experience any of the following symptoms, stop using ciprofloxacin injection and call your doctor immediately: seizures; tremors; dizziness; lightheadedness; headaches that won't go away (with or without blurred vision); difficulty falling asleep or staying asleep; nightmares; not trusting others or feeling that others want to hurt you; hallucinations (seeing things or hearing voices that do not exist); thoughts or actions towards hurting or killing yourself; feeling restless, anxious, nervous, depressed, or confused, or other changes in your mood or behavior.
Using ciprofloxacin injection may worsen muscle weakness in people with myasthenia gravis (a disorder of the nervous system that causes muscle weakness) and cause severe difficulty breathing or death. Tell your doctor if you have myasthenia gravis. Your doctor may tell you not to use ciprofloxacin injection. If you have myasthenia gravis and your doctor tells you that you should use ciprofloxacin injection, call your doctor immediately if you experience muscle weakness or difficulty breathing during your treatment.
Talk to your doctor about the risks of using ciprofloxacin injection.
Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with ciprofloxacin injection. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (http://www.fda.gov/Drugs) or the manufacturer's website to obtain the Medication Guide.
Why is this medication prescribed?
Ciprofloxacin injection is used to treat certain infections caused by bacteria such as pneumonia; and infections of the skin, bone, joint, abdomen (stomach area), urinary tract, and prostate (male reproductive gland). Ciprofloxacin injection is also used to treat patients who have fever and are at high risk for infection because they have very few white blood cells. Ciprofloxacin injection is also used to prevent or treat plague (a serious infection that may be spread on purpose as part of a bioterror attack) and inhalation anthrax (a serious infection that may be spread by anthrax germs in the air on purpose as part of a bioterror attack) . Ciprofloxacin may also be used to treat bronchitis and sinus infections, but should not be used for these conditions if there are other treatment options available. Ciprofloxacin injection is in a class of antibiotics called fluoroquinolones. It works by killing bacteria that cause infections.
Antibiotics such as ciprofloxacin injection will not work for colds, flu, or other viral infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment.
How should this medicine be used?
Ciprofloxacin injection comes as a solution (liquid) to be given through a needle or catheter placed in your vein. It is usually infused (injected slowly) intravenously (into a vein) over a period of 60 minutes, usually once every 8 or 12 hours. The length of your treatment depends on the type of infection you have. Your doctor will tell you how long to use ciprofloxacin injection.
You may receive ciprofloxacin injection in a hospital or you may use the medication at home. If you will be using ciprofloxacin injection at home, your healthcare provider will show you how to infuse the medication. Be sure that you understand these directions, and ask your healthcare provider if you have any questions. Ask your healthcare provider what to do if you have any problems infusing ciprofloxacin injection.
You should begin feeling better during the first few days of your treatment with ciprofloxacin injection. If your symptoms do not improve, or if they get worse, call your doctor.
Use ciprofloxacin injection until you finish the prescription, even if you feel better. Do not stop using ciprofloxacin injection without talking to your doctor unless you experience certain serious side effects listed in the IMPORTANT WARNING or SIDE EFFECTS sections. If you stop using ciprofloxacin injection too soon or if you skip doses, your infection may not be completely treated and the bacteria may become resistant to antibiotics.
Other uses for this medicine
In the event of biological warfare, ciprofloxacin may be used to treat and prevent dangerous illnesses that are deliberately spread such as , tularemia, and anthrax of the skin or mouth. Ciprofloxacin injection is also sometimes used to treat cat scratch disease (an infection that may develop after a person is bitten or scratched by a cat), Legionnaires' disease (type of lung infection), and infections of the outer ear that spread to the bones of the face. Ciprofloxacin injection is also sometimes used to prevent infections in people who are having certain types of surgery.Talk to your doctor about the risks of using this medication for your condition.
This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.
What special precautions should I follow?
Before using ciprofloxacin injection,
- tell your doctor and pharmacist if you are allergic or have had a severe reaction to ciprofloxacin or any other quinolone or fluoroquinolone antibiotic such as gatifloxacin (Tequin) (not available in the U.S.), gemifloxacin (Factive), levofloxacin (Levaquin), lomefloxacin (Maxaquin) (not available in the U.S.), moxifloxacin (Avelox), nalidixic acid (NegGram) (not available in the U.S.), norfloxacin (Noroxin) (not available in the U.S.), ofloxacin (Floxin), and sparfloxacin (Zagam) (not available in the U.S.), or if you are allergic to any other medications.
- tell your doctor if you are taking tizanidine (Zanaflex). Your doctor will probably tell you not to use ciprofloxacin injection while you are taking this medication.
- tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention the medications listed in the IMPORTANT WARNING section and any of the following: anticoagulants ('blood thinners') such as warfarin (Coumadin, Jantoven); certain antidepressants; antipsychotics (medications to treat mental illness) such as clozapine (Clozaril, FazaClo, Versacloz) and olanzapine (Zyprexa, in Symbax); athizromycin (Zithromax, Zmax); caffeine or medications that contain caffeine (Excedrin, NoDoz, Vivarin, others); clarithromycin (Biaxin, in Prevpac); cyclosporine (Gengraf, Neoral, Sandimmune); diuretics ('water pills'); duloxetine (Cymbalta); erythromycin (E.E.S., Eryc, Eryped, others); lidocaine (Xylocaine); certain medications for irregular heartbeat such as amiodarone (Cordarone, Nexterone, Pacerone), disopyramide (Norpace), procainamide , quinidine, and sotalol (Betapace, Betapace AF, Sorine, Sotylize); medications for diabetes that are taken by mouth such as glimepiride (Amaryl, in Duetact), and glyburide (DiaBeta, Glynase, in Glucovance); methotrexate (Otrexup, Rasuvo, Trexall); nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, Naprosyn, others); phenytoin (Dilantin, Phenytek); probenecid (Probalan, in Col-Probenecid); ropinirole (Requip); sildenafil (Revatio, Viagra);or theophylline (Elixophyllin, Theo-24, Uniphyl others). Your doctor may need to change the doses of your medications or monitor you carefully for side effects. Many other medications may also interact with ciprofloxacin, so be sure to tell your doctor about all the medications you are taking, even those that do not appear on this list.
- tell your doctor if you or anyone in your family has or has ever had prolonged QT interval (a rare heart problem that may cause irregular heartbeat, fainting, or sudden death) or if you have or have ever had an irregular heartbeat, heart failure (condition in which the heart is unable to pump enough blood to the other parts of the body), a heart attack, or a slow heartbeat; or have a low level of potassium or magnesium in your blood. Also tell your doctor if you have or have ever had liver disease.
- tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while using ciprofloxacin injection, call your doctor.
- Do not drive a car, operate machinery, or participate in activities requiring alertness or coordination until you know how this medication affects you.
- plan to avoid unnecessary or prolonged exposure to sunlight or ultraviolet light (tanning beds and sunlamps) and to wear protective clothing, sunglasses, and sunscreen. Ciprofloxacin injection may make your skin sensitive to sunlight or ultraviolet light. If your skin becomes reddened, swollen, or blistered, like a bad sunburn, call your doctor.
What special dietary instructions should I follow?
Do not drink or eat a lot of caffeine-containing products such as coffee, tea, energy drinks, cola, or chocolate. Ciprofloxacin injection may increase nervousness, sleeplessness, heart pounding, and anxiety caused by caffeine.
Make sure you drink plenty of water or other fluids every day while you are using ciprofloxacin injection.
What should I do if I forget a dose?
Infuse the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not infuse a double dose to make up for a missed one.
What side effects can this medication cause?
Ciprofloxacin injection may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:
- stomach pain
- pale skin
- unusual tiredness
- irritation, pain, tenderness, redness, warmth, or swelling at the injection spot
If you experience any of the following symptoms, or any of the symptoms described in the IMPORTANT WARNING section, stop using ciprofloxacin injection and call your doctor immediately or get emergency medical help:
- severe diarrhea (watery or bloody stools) that may occur with or without fever and stomach cramps (may occur up to 2 months or more after your treatment)
- peeling or blistering of the skin
- swelling of the eyes, face, mouth, lips, tongue, throat, hands, feet, ankles or lower legs
- difficulty breathing or swallowing
- ongoing or worsening cough
- fast or fluttering heartbeat
- loss of consciousness
- yellowing of the skin or eyes
- dark urine
- light colored stool
- decreased urination
- unusual bruising or bleeding
- joint or muscle pain
Ciprofloxacin injection may cause problems with bones, joints, and tissues around joints in children. Ciprofloxacin injection should not normally be given to children younger than 18 years of age unless they have certain serious infections that cannot be treated with other antibiotics or they have been exposed to plague or anthrax in the air. If your doctor prescribes ciprofloxacin injection for your child, be sure to tell the doctor if your child has or has ever had joint-related problems. Call your doctor if your child develops joint problems, such as pain or swelling, while using ciprofloxacin injection or after treatment with ciprofloxacin injection.
Talk to your doctor about the risks of using ciprofloxacin injection or giving ciprofloxacin injection to your child.
Ciprofloxacin injection may cause other side effects. Call your doctor if you have any unusual problems while using this medication.
If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online (http://www.fda.gov/Safety/MedWatch) or by phone (1-800-332-1088).
In case of emergency/overdose
In case of overdose, call the poison control helpline at 1-800-222-1222. Information is also available online at https://www.poisonhelp.org/help. If the victim has collapsed, had a seizure, has trouble breathing, or can't be awakened, immediately call emergency services at 911.
What other information should I know?
Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check your body's response to ciprofloxacin injection.
It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
- Cipro® I.V.