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Fluoroquinolone Use and Risk of Dysglycemia in Diabetics

A new consideration when prescribing antibiotics to persons with type 2 diabetes….

Previous case reports and observational studies raise the question: is the use of fluoroquinolones associated with severe dysglycemia (hypo- or hyperglycemia) in the diabetic population? People with diabetes are at increased risk of infection and the broad spectrum coverage of fluoroquinolones have led to their increased use over the past several years. However, numerous case reports and observational studies have linked the use of fluoroquinolones to severe dysglycemia. In fact, in 2006, the manufacturer of gatifloxacin (Tequin®) pulled their drug off the market after it was linked to side effects such as severe fluctuations in blood sugars requiring hospitalization.

A recent study in Taiwan looked at the use of levofloxacin, ciprofloxacin, moxifloxacin in diabetic patients and the development of dysglycemia. This cohort study assessed diabetic patients who were new users of oral formulations of levofloxacin, ciprofloxacin, moxifloxacin, cephalosporins, and macrolides on an outpatient basis from January 2006 to November 2007. Cephalosporins and macrolides were included as the "control" groups instead of placebo/no antibiotic treatment group in attempts to control for dysglycemia caused by infection in persons with diabetes. A total of 78,433 patients were included in the study; results were assessed for development of severe dysglycemia, separated into hyperglycemia and hypoglycemia, and reported as absolute risk (AR), adjusted odds ratio (AOR) and confidence intervals (CI). Development of severe dysglycemia was defined as emergency department visit or hospitalization due to dysglycemia within 30 days of initiation of therapy.

There were 640 severe dysglycemia events identified in the study: 215 hyperglycemia and 425 hypoglycemia events. Absolute risk of hyperglycemia per 1000 persons was reported as 1.6 for macrolides, 2.1 for cephalosporins, 6.9 for moxifloxacin, 3.9 for levofloxacin, and 4.0 for ciprofloxacin and AR of hypoglycemia per 1000 persons was reported as 3.7 for macrolides, 3.2 for cephalosporins, 10.0 for moxifloxacin, 9.3 for levofloxacin, and 7.9 for ciprofloxacin. Odds ratios/CI also showed a significant correlation between fluoroquinolone use and dysglycemia.

The results demonstrate that moxifloxacin, followed by levofloxacin and ciprofloxacin, has the highest correlation to development of hypoglycemia amongst those with diabetes; results were similar for development of hyperglycemia. The incidence of severe dysglycemia with fluoroquinolone use is low but it is something prescribing physicians should keep in mind when choosing antibiotic therapy in persons with diabetes.

Practice Pearls:

  • Infections alone can cause severe dysglycemia in diabetes patients
  • There is a casual relationship between fluoroquinolone use in diabetes patients and development of severe dysglycemia
  • Moxifloxacin shows the highest association with dysglycemia in diabetes patients, especially hypoglycemia, followed by levofloxacin and ciprofloxacin

Chou, H. et al. Risk of Severe Dysglycemia Among Diabetic Patients Receiving Levofloxacin, Ciprofloxacin, or Moxifloxacin in Taiwan. Clinical Infectious Diseases 2013;57(7):971–80