Published: December 1999
Revised: January 2000

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Doxycycline and Oesophageal Ulceration

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Prescriber Update 19: 33-34
December 1999, Updated January 2000

Medsafe Editorial Team

The Centre for Adverse Reactions Monitoring has received 34 reports of oesophagitis with doxycycline, and in 1996 13 New Zealanders were hospitalised as a result of this adverse reaction. Medical practitioners and pharmacists should verbally advise patients given doxycycline of the need to take it with a meal. Alternatively, it could be taken with a large glass of water or other fluid and the patient remain upright, either standing or sitting, for at least half an hour after administration.

CARM has received 34 reports of oesophagitis with doxycycline

The Centre for Adverse Reactions Monitoring (CARM) holds 34 reports of oesophagitis with doxycycline.¹ In 1996 13 New Zealanders suffered sufficiently severe oesophageal ulceration to be admitted to hospital. Three were hospitalised for 5 days. Both the CARM and hospitalisation figures will be merely the tip of the iceberg for this readily preventable adverse reaction.

Symptoms can develop in minutes but can take some weeks to resolve

The symptoms may develop as a searing and burning pain within minutes of ingestion of the tablet or capsule, and are sometimes associated with a sensation of something being stuck in the oesophagus. In 1 case reported to CARM, the patient took doxycycline with "plenty of water", but it is not clear how long after the dose she went to bed. The symptoms usually resolve within a few days of cessation of doxycycline, but for severe cases complete recovery may take longer than 2 weeks.

Take doxycycline with a meal

There is a wide range of advice about taking oral doxycycline. The data sheet for Doxy-50 and Doxy-100 tablets and capsules recommends that "doxycycline should be administered with adequate amounts of fluid or food and the patient should remain sitting or standing for up to 2 hours afterwards to prevent the possible development of oesophageal irritation." Martindale advises remaining upright for at least one hour after ingestion but documentary support for this advice, or the data sheet advice of 2 hours, has not been found. The dosage instructions for alendronate (Fosamax)⁴, which is associated with a high incidence of oesophageal ulceration, recommends remaining upright for 30 minutes and then eating.

The best advice for doxycycline in order to minimise the risk of oesophagitis is probably to take it with a meal. Alternatively, it could be taken with a large glass of water or other fluid and the patient should then remain upright for at least 30 minutes.  Doxycycline can be taken with food with minimal effect on absorption.² Medical practitioners and pharmacists should verbally advise patients of these dosage instructions.

Oesophageal symptoms have also been associated with other orally administered medicines³ including other tetracyclines, emepronium carrageenate (Cetiprin Novum), mycophenolate mofetil (Cellcept), NSAIAs, ascorbic acid, potassium chloride, clindamycin, mexiletine, penicillamine, theophylline and quinidine, illustrating the need to take any capsules or tablets with adequate quantities of water.

References

1. Medication-induced oesophagitis. Prescriber Update No.1, May 1993, p.9.
2. Doxy-50, Doxy-100 data sheet
3. Dukes MNG (Ed). Meyler’s Side Effects of Drugs 13^th Edn, Elsevier, Amsterdam, 1996
4. Alendronate and oesophageal ulceration. Prescriber Update No.16, Apr 1998, p.32-3