Fluoroquinolone Use and the Potential Risk for Aortic Aneurysm or Dissection

Fluoroquinolone Use and the Potential Risk for Aortic Aneurysm or Dissection Posted By:
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Fluoroquinolones have long been a popular class of antibiotics for use in a myriad of infections. There are even newer fluoroquinolones that have been developed with a broader spectrum of activity, including better coverage of gram-positive organisms and anaerobes. However, there are major toxicities and adverse effects associated with some of these agents. In December 2018, the US Food and Drug Administration issued a warning highlighting the risk of developing aortic aneurysm or dissection with fluoroquinolones and recommended avoiding their use in patients with known aortic aneurysm or with risk factors for aneurysm, such as Marfan's syndrome, Ehlers-Danlos syndrome, peripheral atherosclerotic vascular diseases, hypertension, and advanced age. The causal role of fluoroquinolones in the development of aortic aneurysm and dissection, however, is still unclear.

In a cohort study in Sweden, fluoroquinolone use (360,088 fluoroquinolone treatment episodes) was associated with an increased risk of aortic aneurysm within 60 days of treatment initiation when compared with amoxicillin use (1.2 vs 0.7 cases per 1000 person-years) in propensity-matched controls. The estimated absolute difference was 82 cases of aortic aneurysm or dissection per 1 million treatment episodes.

The observational nature of this study leaves room for potential confounders (eg, severity of the infection for which the antibiotic was prescribed, smoking status, baseline blood pressure). If a causal role exists between fluoroquinolones and aortic aneurysm or dissection, the absolute risk is small and likely limited to individuals with predisposing risk factors. It is unclear whether it is beneficial to preferentially avoiding fluoroquinolones in patients with any risk factor for aortic aneurysm or dissection (eg, hypertension or older age) versus those with strong risk factors (eg, known aneurysm). When considering fluoroquinolone use, we should always take this uncertainty into account and weigh the overall risk-benefit ratio in each patient.

References
  • Daneman N, Lu H, Redelmeier DA. Fluoroquinolones and collagen associated severe adverse events: a longitudinal cohort study. BMJ Open. 2015;5:e010077.
  • Lee CC, Lee MG, Hsieh R, et al. Oral fluoroquinolone and the risk of aortic dissection. J Am Coll Cardiol. 2018;72:1369.
  • Lee CC, Lee MT, Chen YS, et al. Risk of aortic dissection and aortic aneurysm in patients taking oral fluoroquinolone. JAMA Intern Med. 2015;175:1839.
  • Pasternak B, Inghammar M, Svanström H. Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ. 2018;360:k678.
  • Singh S, Nautiyal A. Aortic dissection and aortic aneurysms associated with fluoroquinolones: a systematic review and meta-analysis. Am J Med. 2017;130:1449.
  • US Food and Drug Administration. Fluoroquinolone antibiotics: safety communication - increased risk of ruptures or tears in the aorta blood vessel in certain patients. www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm628960.htm. Accessed March 29, 2019.

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Filed under: Infectious Diseases , Cardiometabolic

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