Quinolone

Certain Antibiotics Tied to Blood Sugar Swings in Diabetics.

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Diabetes patients who take a certain class of antibiotics are more likely to have severe blood sugar fluctuations than those who take other types of the drugs, a new study finds.

The increased risk was low but doctors should consider it when prescribing the class of antibiotics, known as fluoroquinolones, to people with diabetes, the researchers said. This class of antibiotics, which includes drugs such as Cipro(ciprofloxacin), Levaquin (levofloxacin) and Avelox(moxifloxacin), is commonly used to treat conditions such as urinary tract infections and community-acquired pneumonia.

One expert said the study should serve as a wake-up call for doctors.

“Given a number of alternatives, physicians may consider prescribing alternate antibiotics … in the place of fluoroquinolones (particularly moxifloxacin) to patients with diabetes,” said Dr. Christopher Ochner, assistant professor of pediatrics and adolescent medicine at the Icahn School of Medicine at Mount Sinai, in New York City. “In general, this study demonstrates that closer attention needs to be paid to particular drug-condition interactions.”

The study included about 78,000 people with diabetes in Taiwan. The researchers looked at the patients’ use of three classes of antibiotics: fluoroquinolones; second-generation cephalosporins (cefuroxime, cefaclor, or cefprozil); or macrolides (clarithromycin or azithromycin).

The investigators also looked for any emergency-room visits or hospitalizations for severe blood sugar swings among the patients in the 30 days after they started taking the antibiotics.

The results showed that patients who took fluoroquinolones were more likely to have severe blood sugar swings than those who took antibiotics in the other classes. The level of risk varied according to the specific fluoroquinolone, according to the study, which was published in the journal Clinical Infectious Diseases.

The incidence of hyperglycemia (high blood sugar) per 1,000 people was 6.9 for people taking moxifloxacin, 3.9 for levofloxacin and 4.0 for ciprofloxacin. The incidence of hypoglycemia (low blood sugar) was 10 per 1,000 for moxifloxacin, 9.3 for levofloxacin and 7.9 for ciprofloxacin.

The incidence of hyperglycemia per 1,000 people was 1.6 for those taking the macrolide class of antibiotics and 2.1 for those on cephalosporins. The incidence of hypoglycemia per 1,000 people was 3.7 for macrolides and 3.2 for cephalosporins.

“Our results identified moxifloxacin as the drug associated with the highest risk of hypoglycemia, followed by levofloxacin and ciprofloxacin,” wrote Dr. Mei-Shu Lai, at National Taiwan University, and colleagues.

They said doctors should consider other antibiotics if they have concerns that patients might experience severe blood sugar swings.

“The study … does not prove a causal connection between particular fluoroquinolones and blood sugar dysregulation,” Ochner said. But he believes that it provides evidence that people with diabetes may be at special risk from moxifloxacin in particular.

“If moxifloxacin is to be prescribed to diabetic patients, there should be some additional expected benefit that justifies the increase in incurred risk,” Ochner said.

But another expert said there could be other explanations for why people on fluoroquinolones had more blood sugar fluctuations.

“It is hard to draw conclusions that fluoroquinolones themselves are the culprit, as all of these patients had infections, and infection can lead to hypo- or hyperglycemia in persons with diabetes,” said Dr. Alyson Myers, an endocrinologist at North Shore University Hospital in Manhasset, N.Y.

“In addition, those in the fluoroquinolone group were more likely to have chronic kidney disease or steroid use – the former can increase rates of hypoglycemia and the latter can increase rates of hyperglycemia,” Myers said. “Another confounding factor would be the type of diabetes treatments that patients were receiving, as sulfonylureas and insulin are both associated with greater risks of hypoglycemia than other diabetes medications.”

Source: Drugs.com

Risk of Severe Dysglycemia Among Diabetic Patients Receiving Levofloxacin, Ciprofloxacin, or Moxifloxacin in Taiwan.

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Background. Observational studies and fatal case reports raise concern about the safety of severe dysglycemia associated with fluoroquinolone use. The objective of this study was to assess the risk of severe dysglycemia among diabetic patients who received different fluoroquinolones.

Methods. In a population-based inception cohort study of diabetic patients covering the period from January 2006 to November 2007, outpatient new users of levofloxacin, ciprofloxacin, moxifloxacin, cephalosporins, and macrolides orally were identified. Study events were defined as emergency department visits or hospitalization for dysglycemia within 30 days following the initiation of antibiotic therapy. Results were analyzed with adjusted multinomial propensity score.

Results. A total of 78 433 diabetic patients receiving the antibiotics of interest were included in the study. The absolute risk of hyperglycemia per 1000 persons was 6.9 for moxifloxacin and 1.6 for macrolides. In contrast, the risk of hypoglycemia was 10.0 for moxifloxacin and 3.7 for macrolides. The adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of levofloxacin, ciprofloxacin, and moxifloxacin compared with macrolides were 1.75 (1.12–2.73), 1.87 (1.20–2.93), and 2.48 (1.50–4.12), respectively, for hyperglycemia and 1.79 (1.33–2.42), 1.46 (1.07–2.00), and 2.13 (1.44–3.14), respectively, for hypoglycemia. Patients taking moxifloxacin faced a significantly higher risk of hypoglycemia than those receiving ciprofloxacin. A significant increase in the risk of hypoglycemia was also observed among patients receiving moxifloxacin concomitantly with insulin (AOR, 2.28; 95% CI, 1.22–4.24).

Conclusions. Diabetics using oral fluoroquinolones faced greater risk of severe dysglycemia. The risk of hypoglycemia varied according to the type of fluoroquinolone administered, and was most commonly associated with moxifloxacin.

Source: cid.oxfordjournals.org


Fluoroquinolone Labels Updated to Reflect Heightened Risk for Peripheral Neuropathy.

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The FDA is requiring that the labels of fluoroquinolone antibiotics warn of the drugs’ increased risk for peripheral neuropathy.

The risk has been observed with oral and injectable fluoroquinolones, but not topical agents. Patients could experience peripheral neuropathy any time during their treatment, and it could persist for months or years or be permanent.

Patients should contact their healthcare providers if they develop symptoms consistent with peripheral neuropathy in the arms and legs, including pain, burning, numbness, or weakness; change in sensation to touch, pain, or temperature; or change in the sense of body position.

Patients who develop these symptoms should stop taking the antibiotic and receive alternative therapies unless the benefit of the fluoroquinolone outweighs the risk.

Source: FDA MedWatch safety alert

Fluoroquinolones Linked to Dysglycemia in Patients with Diabetes.

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Fluoroquinolones are associated with increased risk for both hyperglycemia and hypoglycemia among patients with diabetes, compared with other antibiotics, according to a study in Clinical Infectious Diseases.

Researchers in Taiwan used national insurance claims data to identify roughly 78,000 outpatients with diabetes who received a new prescription for an oral antibiotic.

Within 30 days of starting the antibiotic, patients taking moxifloxacin, levofloxacin, or ciprofloxacin had 1.75 to 2.48 times the risk for hyperglycemia-related emergency department visits or hospitalizations, relative to patients taking macrolides. Risks were similarly elevated for episodes of hypoglycemia. Moxifloxacin was associated with the highest risk for dysglycemia.

The authors conclude: “Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously.”

Source: Clinical Infectious Diseases article

Antibiotic Stewardship Program Reduces C. difficile Infection Rates.

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Restricted cephalosporin, fluoroquinolone, and clindamycin use was associated with reduced antibiotic consumption and a decline in the incidence trend of Clostridium difficile infection.

Use of cephalosporins, fluoroquinolones, and clindamycin has repeatedly been associated with increased risk for Clostridium difficile infection (CDI). However, little is known about how CDI rates are affected by antibiotic stewardship programs aimed at decreasing the administration of such “high-risk” antibiotics.

Researchers recently described their experience with a restriction policy for second- and third-generation cephalosporins, fluoroquinolones, and clindamycin at a hospital in Northern Ireland that became effective in January 2008, after a major CDI outbreak in other, affiliated institutions. The policy was devised based on a time-series analysis involving one of these affiliated institutions for the period February 2002 through March 2007, which suggested that treatment of 14 patients with second-generation cephalosporins or 8 with third-generation cephalosporins — versus 94 with amoxicillin/clavulanic acid or 78 with macrolides — would result in one CDI case (Antimicrob Agents Chemother 2009; 53:2082).

Cephalosporins, quinolones, and clindamycin were prescribed significantly less frequently during the study period following implementation of the restriction policy (January 2008–June 2010) than during the 4-year preimplementation period; the use of other antibiotics remained unchanged. The intervention resulted in an overall reduction in antibiotic use and a reversal of the increasing trend for antibiotic consumption. These changes were associated with a significant decline in the incidence trend for CDI (rate decrease, 0.047/1000 bed-days per month). Variations in CDI incidence were affected by the Charlson patient comorbidity index, with a lag of 1 month.

Comment: This report on a successful antibiotic stewardship intervention is a nice example of the cause–effect relationship between antibiotic use and the occurrence of potentially serious nosocomial infections. The authors note that an antimicrobial-management team’s close surveillance of prescribing was key to successful implementation of the restriction policy.

Sourc: Journal Watch Infectious Disease.