"CDC began working with the World Health Organization (WHO) in late February 2003 to investigate and confirm outbreaks of an unusual pneumonia in Southeast Asia. By the time WHO issued a global alert cautioning that the severe respiratory illness "...
The following serious and otherwise important adverse drug reactions are discussed in greater detail in other sections of labeling:
- Disabling and Potentially Irreversible Serious Adverse Reactions [see WARNINGS AND PRECAUTIONS]
- Tendinitis and Tendon Rupture [see WARNINGS AND PRECAUTIONS]
- Peripheral Neuropathy [see WARNINGS AND PRECAUTIONS]
- Central Nervous System Effects [see WARNINGS AND PRECAUTIONS] Exacerbation of Myasthenia Gravis [see WARNINGS AND PRECAUTIONS]
- Other Serious and Sometimes Fatal Adverse Reactions [see WARNINGS AND PRECAUTIONS]
- Hypersensitivity Reactions [see WARNINGS AND PRECAUTIONS]
- Hepatotoxicity [see WARNINGS AND PRECAUTIONS]
- Serious Adverse Reactions with Concomitant Theophylline [see WARNINGS AND PRECAUTIONS]
- Clostridium difficile-Associated Diarrhea [see WARNINGS AND PRECAUTIONS]
- Prolongation of the QT Interval [see WARNINGS AND PRECAUTIONS]
- Musculoskeletal Disorders in Pediatric Patients [see WARNINGS AND PRECAUTIONS]
- Photosensitivity/Phototoxicity [see WARNINGS AND PRECAUTIONS]
- Development of Drug Resistant Bacteria [see WARNINGS AND PRECAUTIONS]
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
During clinical investigations with oral and parenteral CIPRO, 49,038 patients received courses of the drug.
The most frequently reported adverse reactions, from clinical trials of all formulations, all dosages, all drug-therapy durations, and for all indications of ciprofloxacin therapy were nausea (2.5%), diarrhea (1.6%), liver function tests abnormal (1.3%), vomiting (1%), and rash (1%).
Table 6: Medically Important Adverse Reactions That
Occurred In less than 1% of Ciprofloxacin Patients
|System Organ Class||Adverse Reactions|
|Body as a Whole||Headache Abdominal Pain/Discomfort Pain|
|Central Nervous System||Restlessness
Seizures (including Status Epilepticus)
Depression (potentially culminating in self-injurious behavior (such as suicidal ideations/thoughts and attempted or completed suicide)
|Skin/Hypersensitivity||Anaphylactic Reactions including life-threatening anaphylactic shock
Toxic Epidermal Necrolysis
|Special Senses||Blurred Vision
Disturbed Vision (chromatopsia and photopsia)
Decreased Visual Acuity
In randomized, double-blind controlled clinical trials comparing CIPRO tablets [500 mg two times daily (BID)] to cefuroxime axetil (250 mgâ€“500 mg BID) and to clarithromycin (500 mg BID) in patients with respiratory tract infections, CIPRO demonstrated a CNS adverse reaction profile comparable to the control drugs.
Short (6 weeks) and long term (1 year) musculoskeletal and neurological safety of oral/intravenous ciprofloxacin, was compared to a cephalosporin for treatment of cUTI or pyelonephritis in pediatric patients 1 to 17 years of age (mean age of 6 ± 4 years) in an international multicenter trial. The duration of therapy was 10 to 21 days (mean duration of treatment was 11 days with a range of 1 to 88 days). A total of 335 ciprofloxacin-and 349 comparator-treated patients were enrolled.
An Independent Pediatric Safety Committee (IPSC) reviewed all cases of musculoskeletal adverse reactions including abnormal gait or abnormal joint exam (baseline or treatment-emergent). Within 6 weeks of treatment initiation, the rates of musculoskeletal adverse reactions were 9.3% (31/335) in the ciprofloxacin-treated group versus 6% (21/349) in comparator-treated patients. All musculoskeletal adverse reactions occurring by 6 weeks resolved (clinical resolution of signs and symptoms), usually within 30 days of end of treatment. Radiological evaluations were not routinely used to confirm resolution of the adverse reactions. Ciprofloxacin-treated patients were more likely to report more than one adverse reaction and on more than one occasion compared to control patients. The rate of musculoskeletal adverse reactions was consistently higher in the ciprofloxacin group compared to the control group across all age subgroups. At the end of 1 year, the rate of these adverse reactions reported at any time during that period was 13.7% (46/335) in the ciprofloxacin-treated group versus 9.5% (33/349) in the comparator-treated patients (Table 7).
Table 7: Musculoskeletal Adverse Reactions1 as
Assessed by the IPSC
|All Patients (within 6 weeks)||31/335 (9.3%)||21/349 (6%)|
|95% Confidence Interval2||(-0.8%, +7.2%)|
|12 months < 24 months||1/36 (2.8%)||0/41|
|2 years < 6 years||5/124 (4%)||3/118 (2.5%)|
|6 years < 12 years||18/143 (12.6%)||12/153 (7.8%)|
|12 years to 17 years||7/32 (21.9%)||6/37 (16.2 %)|
|All Patients (within 1 year)||46/335 (13.7%)||33/349 (9.5%)|
|95% Confidence Interval1||(-0.6%, + 9.1%)|
|1Included: arthralgia, abnormal gait, abnormal
joint exam, joint sprains, leg pain, back pain, arthrosis, bone pain, pain,
myalgia, arm pain, and decreased range of motion in a joint (knee, elbow,
ankle, hip, wrist, and shoulder)
2The study was designed to demonstrate that the arthropathy rate for the ciprofloxacin group did not exceed that of the control group by more than + 6%. At both the 6 week and 1 year evaluations, the 95% confidence interval indicated that it could not be concluded that the ciprofloxacin group had findings comparable to the control group.
The incidence rates of neurological adverse reactions within 6 weeks of treatment initiation were 3% (9/335) in the CIPRO group versus 2% (7/349) in the comparator group and included dizziness, nervousness, insomnia, and somnolence.
In this trial, the overall incidence rates of adverse reactions within 6 weeks of treatment initiation were 41% (138/335) in the ciprofloxacin group versus 31% (109/349) in the comparator group. The most frequent adverse reactions were gastrointestinal: 15% (50/335) of ciprofloxacin patients compared to 9% (31/349) of comparator patients. Serious adverse reactions were seen in 7.5% (25/335) of ciprofloxacintreated patients compared to 5.7% (20/349) of control patients. Discontinuation of drug due to an adverse reaction was observed in 3% (10/335) of ciprofloxacin-treated patients versus 1.4% (5/349) of comparator patients. Other adverse reactions that occurred in at least 1% of ciprofloxacin patients were diarrhea 4.8%, vomiting 4.8%, abdominal pain 3.3%, dyspepsia 2.7%, nausea 2.7%, fever 2.1%, asthma 1.8% and rash 1.8%.
Short-term safety data for ciprofloxacin was also collected in a randomized, double-blind clinical trial for the treatment of acute pulmonary exacerbations in cystic fibrosis patients (ages 5â€“17 years). Sixty seven patients received CIPRO IV 10 mg/kg/dose every 8 hours for one week followed by CIPRO tablets 20 mg/kg/dose every 12 hours to complete 10â€“21 days treatment and 62 patients received the combination of ceftazidime intravenous 50 mg/kg/dose every 8 hours and tobramycin intravenous 3 mg/kg/dose every8 hours for a total of 10â€“21 days. Periodic musculoskeletal assessments were conducted by treatment-blinded examiners. Patients were followed for an average of 23 days after completing treatment (range 0â€“ 93 days). Musculoskeletal adverse reactions were reported in 22% of the patients in the ciprofloxacin group and 21% in the comparison group. Decreased range of motion was reported in 12% of the subjects in the ciprofloxacin group and 16% in the comparison group. Arthralgia was reported in 10% of the patients in the ciprofloxacin group and 11% in the comparison group. Other adverse reactions were similar in nature and frequency between treatment arms. The efficacy of CIPRO for the treatment of acute pulmonary exacerbations in pediatric cystic fibrosis patients has not been established.
In addition to the adverse reactions reported in pediatric patients in clinical trials, it should be expected that adverse reactions reported in adults during clinical trials or postmarketing experience may also occur in pediatric patients.
The following adverse reactions have been reported from worldwide marketing experience with fluoroquinolones, including CIPRO. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure (Table 8).
Table 8: Postmarketing Reports of Adverse Drug Reactions
|System Organ Class||Adverse Reactions|
Torsade de Pointes
Vasculitis and ventricular arrhythmia
|Central Nervous System||Hypertonia
Exacerbation of myasthenia gravis
|Hemic/Lymphatic||Pancytopenia (life threatening or fatal outcome)
|Hepatobiliary||Hepatic failure (including fatal cases)|
|Infections and Infestations||Candidiasis (oral, gastrointestinal, vaginal)|
|Investigations||Prothrombin time prolongation or decrease Cholesterol elevation (serum)
Potassium elevation (serum)
|Skin/Hypersensitivity||Acute generalize exanthematous pustulosis (AGEP)
Fixed eruption Serum sickness-like reaction
Adverse Laboratory Changes
Changes in laboratory parameters while on CIPRO are listed below:
Other changes occurring were: elevation of serum gammaglutamyl transferase, elevation of serum amylase, reduction in blood glucose, elevated uric acid, decrease in hemoglobin, anemia, bleeding diathesis, increase in blood monocytes, and leukocytosis.
Read the Cipro (ciprofloxacin) Side Effects Center for a complete guide to possible side effects
Ciprofloxacin is an inhibitor of human cytochrome P450 1A2 (CYP1A2) mediated metabolism. Co-administration of CIPRO with other drugs primarily metabolized by CYP1A2 results in increased plasma concentrations of these drugs and could lead to clinically significant adverse events of the co-administered drug.
Table 9: Drugs That are Affected by and Affecting
|Drugs That are Affected by CIPRO|
|Tizanidine||Contraindicated||Concomitant administration of tizanidine and CIPRO is contraindicated due to the potentiation of hypotensive and sedative effects of tizanidine [see CONTRAINDICATIONS]|
|Theophylline||Avoid Use (Plasma Exposure Likely to be Increased and Prolonged)||Concurrent administration of CIPRO with theophylline may result in increased risk of a patient developing central nervous system (CNS) or other adverse reactions. If concomitant use cannot be avoided, monitor serum levels of theophylline and adjust dosage as appropriate [see WARNINGS AND PRECAUTIONS].|
|Drugs Known to Prolong QT Interval||Avoid Use||CIPRO may further prolong the QT interval in patients receiving drugs known to prolong the QT interval (for example, class IA or III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics) [see WARNINGS AND PRECAUTIONS and Use in Specific Populations].|
|Oral antidiabetic drugs||Use with caution Glucose-lowering effect potentiated||Hypoglycemia sometimes severe has been reported when CIPRO and oral antidiabetic agents, mainly sulfonylureas (for example, glyburide, glimepiride), were co-administered, presumably by intensifying the action of the oral antidiabetic agent. Fatalities have been reported. Monitor blood glucose when CIPRO is co-administered with oral antidiabetic drugs [see ADVERSE REACTIONS].|
|Phenytoin||Use with caution Altered serum levels of phenytoin (increased and decreased)||To avoid the loss of seizure control associated with decreased phenytoin levels and to prevent phenytoin overdose-related adverse reactions upon CIPRO discontinuation in patients receiving both agents, monitor phenytoin therapy, including phenytoin serum concentration during and shortly after coadministration of CIPRO with phenytoin.|
|Cyclosporine||Use with caution (transient elevations in serum creatinine)||Monitor renal function (in particular serum creatinine) when CIPRO is co-administered with cyclosporine.|
|Anti-coagulant drugs||Use with caution (Increase in anticoagulant effect)||The risk may vary with the underlying infection, age and general status of the patient so that the contribution of CIPRO to the increase in INR (international normalized ratio) is difficult to assess. Monitor prothrombin time and INR frequently during and shortly after co-administration of CIPRO with an oral anti-coagulant (for example, warfarin).|
|Methotrexate||Use with caution Inhibition of methotrexate renal tubular transport potentially leading to increased methotrexate plasma levels||Potential increase in the risk of methotrexate associated toxic reactions. Therefore, carefully monitor patients under methotrexate therapy when concomitant CIPRO therapy is indicated.|
|Ropinirole||Use with caution||Monitoring for ropinirole-related adverse reactions and appropriate dose adjustment of ropinirole is recommended during and shortly after coadministration with CIPRO [see WARNINGS AND PRECAUTIONS].|
|Clozapine||Use with caution||Careful monitoring of clozapine associated adverse reactions and appropriate adjustment of clozapine dosage during and shortly after co-administration with CIPRO are advised.|
|NSAIDs||Use with caution||Non-steroidal anti-inflammatory drugs (but not acetyl salicylic acid) in combination of very high doses of quinolones have been shown to provoke convulsions in pre-clinical studies and in postmarketing.|
|Sildenafil||Use with caution Two-fold increase in exposure||Monitor for sildenafil toxicity [see CLINICAL PHARMACOLOGY].|
|Duloxetine||Avoid Use Five-fold increase in duloxetine exposure||If unavoidable, monitor for duloxetine toxicity|
|Caffeine/Xanthine Derivatives||Use with caution Reduced clearance resulting in elevated levels and prolongation of serum half-life||CIPRO inhibits the formation of paraxanthine after caffeine administration (or pentoxifylline containing products). Monitor for xanthine toxicity and adjust dose as necessary.|
|Drug(s) Affecting Pharmacokinetics of CIPRO|
|Antacids, Sucralfate, Multivitamins and Other Products Containing Multivalent Cations (magnesium/aluminum antacids; polymeric phosphate binders (for example, sevelamer, lanthanum carbonate); sucralfate; Videx® (didanosine) chewable/buffered tablets or pediatric powder; other highly buffered drugs; or products containing calcium, iron, or zinc and dairy products)||CIPRO should be taken at least two hours before or six hours after Multivalent cation-containing products administration [see DOSAGE AND ADMINISTRATION.]||Decrease CIPRO absorption, resulting in lower serum and urine levels|
|Probenecid||Use with caution (interferes with renal tubular secretion of CIPRO and increases CIPRO serum levels)||Potentiation of CIPRO toxicity may occur.|
2. Friedman J, Polifka J. Teratogenic effects of drugs: a resource for clinicians (TERIS). Baltimore, Maryland: Johns Hopkins University Press, 2000:149-195.
3. Loebstein R, Addis A, Ho E, et al. Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study. Antimicrob Agents Chemother. 1998;42(6):1336-1339.
4. Schaefer C, Amoura-Elefant E, Vial T, et al. Pregnancy outcome after prenatal quinolone exposure. Evaluation of a case registry of the European network of teratology information services (ENTIS). Eur J Obstet Gynecol Reprod Biol. 1996;69:83-89.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 1/31/2017
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