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Abstract
Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity.Eccentric stretching is the most effective treatment.Surgical treatment is reserved for recalcitrant cases.Minimally-invasive and tendinoscopic treatments are showing promising results. Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024.
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Affiliation(s)
| | - Audrey Tan
- Jurong Health Services Pte Ltd, Singapore
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2
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Bidell MR, Lodise TP. Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk? Pharmacotherapy 2016; 36:679-93. [DOI: 10.1002/phar.1761] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Ball P. Efficacy and safety of levofloxacin in the context of other contemporary fluoroquinolones: a review. Curr Ther Res Clin Exp 2014; 64:646-61. [PMID: 24944413 DOI: 10.1016/j.curtheres.2003.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2003] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND In recent years, fluoroquinolone research has focused on achieving several goals, including (1) enhanced potency against gram-positive cocci, notably Streptococcus pneumoniae, and anaerobes, while (2) maintaining potency against gram-negative pathogens, (3) optimizing pharmacokinetics and pharmacodynamics (PK/PD), and (4) minimizing potential adverse drug reactions through recognition and avoidance of structural configurations that have characterized earlier, reactive compounds. OBJECTIVE This review examines the efficacy and safety of fluoroquinolones and the specific clinical evidence regarding levofloxacin. METHODS Using published literature collected over time by the author, a review was conducted, focusing on the efficacy and safety profile of levofloxacin and other fluoroquinolones. RESULTS The newer fluoroquinolones have fulfilled many of the research goals described above. Levofloxacin has improved anti-gram-positive potency, PK/PD properties, a proven clinical trial record (particularly for communityacquired pneumonia [CAP]), and an excellent safety profile-in the context of the treatment of >250 million patients worldwide in the past decade. It is licensed for management of drug-resistant S pneumoniae infections in the United States and has gained widespread formulary acceptance and guideline inclusion. Studies assessing levofloxacin for CAP therapy show significant advantages over standard therapy, such as trends toward reduced IV therapy and length of hospitalization, reduced mortality, and significant associated cost reduction. In addition, levofloxacin has proved highly effective in acute exacerbations of chronic bronchitis (AECB), with excellent clinical and bacteriologic results, typical of the class, and significant advantages-in terms of clinical response, overall pathogen eradication, extension of the symptom-free period, and trends toward a reduction in the number of consultation visits and hospitalizations-over standard agents, such as the oral cephalosporins. CONCLUSIONS Levofloxacin offers a combination of documented efficacy and tolerability, and provides an important option for the treatment of bacterial infections, including CAP and AECB, compared with standard agents used in the management of lower respiratory tract infections.
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Affiliation(s)
- Peter Ball
- Lately University of St. Andrews, Fife, Scotland, United Kingdom
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Pham L, Christensen JM, Rodriguez-Proteau R. Pharmacokinetic Prediction of Levofloxacin Accumulation in Tissue and Its Association to Tendinopathy. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/pp.2013.41018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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5
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Abstract
The fluoroquinolone class of antibacterial agents are among the most frequently prescribed drugs, with utility in a broad range of bacterial infections. Although very useful agents, the fluoroquinolones as a class are associated with a number of adverse events, some with considerable clinical significance. In the past 15-20 years, tolerability concerns have led to restrictions on the use of the fluoroquinolones and, in some instances, the withdrawal of agents from the market. This review focuses on the safety and tolerability of levofloxacin, a third-generation fluoroquinolone, relative to other fluoroquinolones. A literature search was performed of the MEDLINE database encompassing the dates 1980-2009, using as keywords the drug names levofloxacin and concurrently marketed fluoroquinolones combined with the words 'safety', 'adverse effect' or 'adverse drug reaction', or the name of the specific adverse effect. Adverse events commonly associated with the fluoroquinolones include gastrointestinal and CNS toxicity (most frequently headache and dizziness), as well as other adverse events including ECG abnormalities (for example QT interval prolongation), disrupted glucose metabolism, phototoxicity, tendon and joint disorders, hypersensitivity and skin disorders, and hepatic toxicity. Package inserts for the fluoroquinolones in Europe and the US contain warnings regarding these risks. US package inserts also carry 'black-box' warnings regarding the risk of tendon rupture and joint disorders with these agents; however, there is a substantial body of evidence to indicate that there are marked differences in the tolerability profiles of the individual agents within the fluoroquinolone class. These differences may be explained, at least in part, by structural differences: all fluoroquinolones share a basic quinolone core, with differences in specific side chains underlying the adverse event relationships. Furthermore, many of the fluoroquinolone-associated adverse effects and toxicities occur more frequently in patients with pre-existing risk factors, or in certain subpopulations. Notably, package inserts for the fluoroquinolones carry warnings regarding use in the elderly, paediatric patients and patients with pre-existing, or factors predisposing to, seizure disorders. Because of this, many adverse reactions with these agents could be prevented by improving patient screening and education. The recent withdrawal of gatifloxacin due to dysglycaemia makes it timely to review the safety and tolerability of the individual agents in this class. Overall, it appears that levofloxacin is relatively well tolerated, with low rates of clinically important adverse events such as CNS toxicity, cardiovascular toxicity and dysglycaemia.
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Affiliation(s)
- Hans H Liu
- Bryn Mawr Medical Specialists, Bryn Mawr, Pennsylvania, USA
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Durey A, Baek YS, Park JS, Lee K, Ryu JS, Lee JS, Cheong MH. Levofloxacin-induced Achilles tendinitis in a young adult in the absence of predisposing conditions. Yonsei Med J 2010; 51:454-6. [PMID: 20376902 PMCID: PMC2852805 DOI: 10.3349/ymj.2010.51.3.454] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Fluoroquinolones (FQs) represent a major class of antimicrobials that have a high potential as therapeutic agents. Although FQs are generally safe for the use as antimicrobials, they may induce tendinopathic complications such as tendinitis and tendon rupture. A number of factors have been suggested to further predispose a patient to such injuries. Hitherto, a few published cases on tendon disorders have implicated levofloxacin, a more recently introduced FQ. Here, we report a patient with levofloxacin-induced Achilles tendinitis, who exhibited no known predisposing factors. A 20-year-old man without any history of disease or medication presented with community-acquired pneumonia. Levofloxacin was administered and 3 days later, he complained of pain in the left Achilles tendon and revealed redness and swelling in the area. On suspecting Achilles tendinitis, levofloxacin treatment was discontinued, and the tendinitis subsequently improved. To our knowledge, this is the first case report on FQ-induced Achilles tendinitis in Korea.
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Affiliation(s)
- Areum Durey
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Yong Soo Baek
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jin Seok Park
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Kwangsoo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jeong-Seon Ryu
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jin-Soo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Moon-Hyun Cheong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
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7
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Abstract
BACKGROUND The pathogenesis of chronic tendinopathy is unclear but it does not appear to be an inflammatory process. Apoptosis may lead to degenerate tissue through a nitric oxide-mediated pathway. Increased levels of nitric oxide have been demonstrated in Achilles tendinopathy. HYPOTHESIS Nitric oxide-mediated apoptosis is an important mechanism in the development of Achilles tendinopathy. STUDY DESIGN Controlled laboratory study. METHODS Samples were obtained from the Achilles tendons of 14 patients with noninsertional Achilles tendinopathy. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on magnetic resonance imaging. Immunohistochemical techniques identified the expression of inducible and endothelial nitric oxide synthase as markers of nitric oxide production. Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) and the demonstration of caspase-3 activation. RESULTS Significant differences were found between the diseased tendon and the controls for all parameters. The mean caspase-3 cell count for diseased tendon was 51.9 versus 28.3 for the controls (P < .001). The mean TUNEL cell count for diseased tendon was 24.1 compared with 14.8 (P < .001). Inducible nitric oxide synthase (iNOS) densitometry revealed a mean of 26.1 for the diseased tissue versus 15.0 for the controls (P < .001) and the values for endothelial nitric oxide synthase (eNOS) were 48.3 and 23.7, respectively (P = .015). CONCLUSION Apoptosis may play a role in the development of noninsertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels. CLINICAL RELEVANCE A clearer understanding of the tendinopathic process may lead to new treatment strategies aimed at modulating apoptosis.
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Affiliation(s)
- Christopher J Pearce
- Department of Trauma and Orthopaedic Surgery, Basingstoke and North Hampshire Hospitals, NHS Foundation Trust, Basingstoke, United Kingdom.
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Aagaard L, Hansen EH. Information about ADRs explored by pharmacovigilance approaches: a qualitative review of studies on antibiotics, SSRIs and NSAIDs. BMC CLINICAL PHARMACOLOGY 2009; 9:4. [PMID: 19254390 PMCID: PMC2656469 DOI: 10.1186/1472-6904-9-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 03/03/2009] [Indexed: 11/29/2022]
Abstract
Background Despite surveillance efforts, unexpected and serious adverse drug reactions (ADRs) repeatedly occur after marketing. The aim of this article is to analyse ADRs reported by available ADR signal detection approaches and to explore which information about new and unexpected ADRs these approaches have detected. Methods We selected three therapeutic cases for the review: antibiotics for systemic use, non-steroidal anti-inflammatory medicines (NSAID) and selective serotonin re-uptake inhibitors (SSRI). These groups are widely used and represent different therapeutic classes of medicines. The ADR studies were identified through literature search in Medline and Embase. The search was conducted in July 2007. For each therapeutic case, we analysed the time of publication, the strengths of the evidence of safety in the different approaches, reported ADRs and whether the studies have produced new information about ADRs compared to the information available at the time of marketing. Results 79 studies were eligible for inclusion in the analysis: 23 antibiotics studies, 35 NSAID studies, 20 SSRI studies. Studies were mainly published from the end of the 1990s and onwards. Although the drugs were launched in different decades, both analytical and observational approaches to ADR studies were similar for all three therapeutic cases: antibiotics, NSAIDs and SSRIs. The studies primarily dealt with analyses of ADRs of the type A and B and to a lesser extent C and D, cf. Rawlins' classification system. The therapeutic cases provided similar results with regard to detecting information about new ADRs despite different time periods and organs attacked. Approaches ranging higher in the evidence hierarchy provided information about risks of already known or expected ADRs, while information about new and previously unknown ADRs was only detected by case reports, the lowest ranking approach in the evidence hierarchy. Conclusion Although the medicines were launched in different decades, approaches to the ADR studies were similar for all three therapeutic cases: antibiotics, NSAIDs and SSRIs. Both descriptive and analytical designs were applied. Despite the fact that analytical studies rank higher in the evidence hierarchy, only the lower ranking descriptive case reports/spontaneous reports provided information about new and previously undetected ADRs. This review underscores the importance of systems for spontaneous reporting of ADRs. Therefore, spontaneous reporting should be encouraged further and the information in ADR databases should continuously be subjected to systematic analysis.
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Affiliation(s)
- Lise Aagaard
- Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, Faculty of Pharmaceutical Sciences, University of Copenhagen, Denmark.
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9
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Abstract
With the expanded use of fluoroquinolones and increasing number of reports of tendon injury linked to these agents, clinicians must be aware of the frequency and strength of this association. In the past, pefloxacin and ciprofloxacin were most frequently implicated, but tendon injury is reported with most fluoroquinolones. As many as half of patients with fluoroquinolone-associated tendinopathy experience tendon rupture, and almost one third have received long-term corticosteroids. Tendon injury is mostly reported in the lower extremities, but injury in the upper extremities, including the hand, has also been reported. Management is similar regardless of the location of the injury. Use of fluoroquinolones requires careful patient assessment and follow-up in view of this complication with potential for sequelae.
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Affiliation(s)
- Yasmin Khaliq
- Department of Pharmacy, Ottawa Hospital General Campus, Ottawa, Ontario K1H 8L6, Canada
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10
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Abstract
Several parenteral antimicrobials have been introduced into clinical practice over the course of the last decade. Some of these agents (e.g., linezolid, daptomycin, and tigecycline) are prototypes of new classes of compounds. In comparative clinical trials, these newer anti-infectives have been shown to be safe and to have low rates of discontinuation by patients. However, long-term use has revealed unique toxicities associated with the use of some of these drugs. The adverse events and potential drug interactions associated with the use of these antibiotics are variable and require familiarity with the safety profile of each drug. It is especially important that clinicians be able to recognize serious adverse events associated with the use of specific drugs, because most of the adverse events can be readily reversed by cessation of therapy.
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Affiliation(s)
- Gary E Stein
- Department of Medicine, Michigan State University, East Lansing, MI 48824, USA.
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11
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Abstract
Fluoroquinolones are the most potent oral antibiotics in clinical use today. Increasingly, these drugs are being prescribed for relatively benign infections and for new categories of patients, including paediatric patients. As their use becomes more frequent, so will the adverse events. This review focuses on a rare but debilitating adverse reaction, the fluoroquinolone-associated tendinopathy. Despite many published case reports and approximately 3500 cases reported to the World Health Organization Collaborating Centre for Drug Monitoring, little is known about the mechanisms behind this fluoroquinolone-specific toxicity. Data on chemical properties, mode of action, pharmacokinetic features, clinical presentation and risk factors in relation to tendon toxicity are discussed and the literature reviewed. As long as the musculoskeletal toxicity cannot be predicted by in vitro or in vivo models and this class of antibiotics is one of the most commonly linked to selection of resistant bacteria, a more prudent use of fluoroquinolones is warranted.
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Affiliation(s)
- Asa Melhus
- Lund University, Department of Medical Microbiology, Malmö University Hospital, S-205 02 Malmö, Sweden.
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12
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Mitscher LA. Bacterial topoisomerase inhibitors: quinolone and pyridone antibacterial agents. Chem Rev 2005; 105:559-92. [PMID: 15700957 DOI: 10.1021/cr030101q] [Citation(s) in RCA: 591] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lester A Mitscher
- Department of Medicinal Chemistry and Molecular Biosciences and The Chemical Methodologies and Library Development Center of Excellence, The University of Kansas, Lawrence, Kansas 66045-7582, USA.
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Braun D, Petitpain N, Cosserat F, Loeuille D, Bitar S, Gillet P, Trechot P. Rupture of multiple tendons after levofloxacin therapy. Joint Bone Spine 2004; 71:586-7. [PMID: 15589446 DOI: 10.1016/j.jbspin.2003.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Accepted: 10/15/2003] [Indexed: 10/26/2022]
Abstract
An 80-year-old man treated by levofloxacin developed multiple tendon ruptures. His symptoms resolved over 9 months after levofloxacin discontinuation. Nasal corticosteroid therapy, aging and chronic respiratory insufficiency were probably predisposing factors in this patient.
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Affiliation(s)
- Denis Braun
- Pneumology Department, Maillot Hospital, 54150 Briey, France
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14
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Arruabarrena Sánchez C, Guhl Millán G, Serrano Simarro P. Tendinitis por ciprofloxacino: a propósito de un caso. Semergen 2004. [DOI: 10.1016/s1138-3593(04)74317-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis 2003; 36:1404-10. [PMID: 12766835 DOI: 10.1086/375078] [Citation(s) in RCA: 244] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2002] [Accepted: 02/06/2003] [Indexed: 11/03/2022] Open
Abstract
With the expanded use of fluoroquinolones for the treatment of community-acquired respiratory infections and reports of tendon injury linked to the use of these agents, we reviewed the literature to investigate the frequency and strength of this association. Ninety-eight case reports were available for review. The incidence of tendon injury associated with fluoroquinolone use is low in a healthy population but increases in patients who have renal dysfunction, who are undergoing hemodialysis, or who have received renal transplants. Pefloxacin and ciprofloxacin were most frequently implicated, but tendon injury was reported with most fluoroquinolones. The median duration of fluoroquinolone treatment before the onset of tendon injury was 8 days, although symptoms occurred as early as 2 hours after the first dose and as late as 6 months after treatment was stopped. Up to one-half of patients experienced tendon rupture, and almost one-third received long-term corticosteroid therapy. Tendon injury associated with fluoroquinolone use is significant, and risk factors such as renal disease or concurrent corticosteroid use must be considered when these agents are prescribed.
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Affiliation(s)
- Yasmin Khaliq
- Department of Pharmacy, Ottawa Hospital General Campus, Ottawa, Canada
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Schindler C, Pittrow D, Kirch W. Reoccurrence of levofloxacin-induced tendinitis by phenoxymethylpenicillin therapy after 6 months: a rare complication of fluoroquinolone therapy? Chemotherapy 2003; 49:90-1. [PMID: 12756981 DOI: 10.1159/000069776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Christoph Schindler
- Institute of Clinical Pharmacology, Medical Faculty of the Dresden University of Technology, Dresden, Germany.
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Leone R, Venegoni M, Motola D, Moretti U, Piazzetta V, Cocci A, Resi D, Mozzo F, Velo G, Burzilleri L, Montanaro N, Conforti A. Adverse drug reactions related to the use of fluoroquinolone antimicrobials: an analysis of spontaneous reports and fluoroquinolone consumption data from three italian regions. Drug Saf 2003; 26:109-20. [PMID: 12534327 DOI: 10.2165/00002018-200326020-00004] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To analyse and compare with one another and with other antibacterial drugs the adverse drug reactions (ADRs) of the different fluoroquinolones currently used in Italy, spontaneously reported from doctors in three northern Italian regions. METHODS The data on fluoroquinolones and other antibacterials were obtained from the spontaneous reporting system database of Emilia Romagna, Lombardy and the Veneto, which are the principal contributors to the Italian spontaneous surveillance system. The fluoroquinolone ADRs with a causality assessment of certain, probable or possible (according to WHO criteria), reported between January 1999 and December 2001, were selected and toxicity profiles of individual drugs were described and compared with one another. The reports were also correlated with sex and age of patients and with regional prescription data to estimate individual fluoroquinolone reporting rate of adverse events. RESULTS During the study period, 10 011 reports were received by the system (a mean annual reporting rate of approximately 185 per million inhabitants): 1920 referred to systemic antimicrobials, of which 432 (22.5%) involved fluoroquinolones. Pefloxacin was associated with the highest reporting rate (982 reports/daily defined dose/1000 inhabitants/day), followed by moxifloxacin (356), rufloxacin (221) and lomefloxacin (196). The most frequently reported reactions to fluoroquinolones involved the skin, but their percentage (25%) was significantly lower (p < 0.01) than those of other systemic antimicrobials (58.5%), whereas the percentages of reactions involving the central nervous (12.2 vs 3.6%), musculoskeletal (14.7 vs 0.3%) and psychiatric systems (9.3 vs 1.8%) were significantly higher (p < 0.01). We found some significant differences in the safety profiles of individual fluoroquinolones: ciprofloxacin was more frequently associated with skin reactions (p < 0.01), levofloxacin and pefloxacin with musculoskeletal (p < 0.01), and rufloxacin with psychiatric disorders (p < 0.05). Levofloxacin was the fluoroquinolone associated with the highest rate of serious tendon disorders; phototoxic reactions were more frequent with lomefloxacin, and toxic epidermal necrolysis and Stevens-Johnson syndrome were seen only with ciprofloxacin. CONCLUSIONS The differences in the safety profiles should be taken into account when prescribing a fluoroquinolone to individual patients.
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Affiliation(s)
- Roberto Leone
- Clinical Pharmacology Unit, WHO Reference Centre for Education and Communication in International Drug Monitoring, University of Verona, Italy.
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