Published: 6 December 2019

Publications

Aortic aneurysm/dissection – The Achilles heel of fluoroquinolones

Prescriber Update 40(4): 90–91
December 2019

Fluoroquinolones, including ciprofloxacin, norfloxacin and moxifloxacin, are associated with an increased risk of aortic aneurysm and aortic dissection.

What is aortic aneurysm and dissection?

Aortic aneurysm is a localised or diffuse dilation of the aorta, while aortic dissection occurs when there is separation of the layers within the aortic wall¹. These conditions are associated with alterations in collagen content, concentrations and structure.

Tendon rupture is known to occur with fluoroquinolone treatment. The aorta contains the same type of collagen as the Achilles tendon. Therefore, fluoroquinolones may degrade the collagen along the aortic wall in a similar way to the collagen in tendons and, as such, contribute to progression or rupture of an aneurysm^1–3. However, the exact mechanism is not known^2–4.

About the risk

The Medicines Adverse Reactions Committee (MARC) discussed the risk of aortic aneurysm and dissection associated with fluoroquinolones at the June 2019 meeting⁵. Data from recent observational studies and overseas case reports indicate patients taking fluoroquinolones have about a two-fold increase in risk in compared with patients taking no antibiotics or other antibiotics (eg, amoxicillin)^2–4.

The annual background risk varies in the literature between 3 and 20 per 100,000 population, and up to 300 per 100,000 among the oldest or for people with other risk factors^6–7. Risk factors include a family history of aneurysm disease, pre-existing aortic aneurysm and/or aortic dissection and atherosclerosis.

New Zealand reports

Up to 31 March 2019, the Centre for Adverse Reactions Monitoring (CARM) had not received any local reports of aortic aneurysm or dissection associated with fluoroquinolone use.

Regulatory action

Regulators overseas have issued warnings about the risk of aortic aneurysm and dissection associated with fluoroquinolones. Medsafe is currently working with the manufacturers of fluoroquinolones to include a similar warning in the New Zealand data sheets.

Advice for healthcare professionals

• For prescribers: if patients have risk factors for aneurysm or dissection, only prescribe fluoroquinolones after careful benefit-risk assessment and after consideration of other therapeutic options.
• For cardiologists and vascular surgeons: please provide information/advice to the general practitioner if screening shows a patient has the potential for developing an aneurysm or dissection⁵.

References

1. University of Rochester Medical Center. Thoracic Aortic Aneurysm and Aortic Dissection. URL: www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=p08258 (accessed 14 October 2019).
2. Pasternak B, Inghammar M, Svanstrom H. 2018. Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ 360: k678. DOI: http://dx.doi.org/10.1136/bmj.k678 (accessed 26 February 2019).
3. Lee C-C, Lee MG, Chen Y-S, et al. 2015. Risk of aortic dissection and aortic aneurysm in patients taking oral fluoroquinolone. JAMA Internal Medicine 175(11): 1839–47. DOI: 10.1001/jamainternmed.2015.5389 (accessed 30 April 2019).
4. Daneman N, Lu H, Redelmeier DA. 2015. Fluoroquinolones and collagen associated severe adverse events: a longitudinal cohort study. BMJ Open 5(11): e010077. DOI: 10.1136/bmjopen-2015-010077 (accessed 10 April 2019).
5. Medsafe. 2019. Minutes of the 178th Medicines Adverse Reaction Committee Meeting. URL: www.medsafe.govt.nz/profs/adverse/Minutes178.htm (accessed 17 October 2019).
6. Lee CC, Lee MG, Hsieh R, et al. 2018. Oral fluoroquinolone and the risk of aortic dissection. Journal of the American College of Cardiology 72(12): 1369–78. DOI: 10.1016/j.jacc.2018.06.067 (accessed 30 April 2019).
7. Howard DP, Banerjee A, Fairhead JF, et al. 2015. Age-specific incidence, risk factors and outcome of acute abdominal aortic aneurysms in a defined population. The British Journal of Surgery 102(8): 907–15. DOI: 10.1002/bjs.9838 (accessed 30 April 2019).