Published: October 2003

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Oesophagitis with Doxycycline and Others

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Prescriber Update 24(2): 30
October 2003

Medsafe Editorial Team

Oesophagitis is a well-documented consequence of doxycycline therapy.  A number of other medicines are similarly implicated.  Taking doses at bedtime or without fluids is a common cause of the oesophagitis.  This adverse effect can be prevented by advising patients to take doxycycline with food or a large glass of water, and to sit upright or stand for at least 30 minutes afterwards.

Dose form may not be a contributing factor
Many other medicines are known to cause oesophagitis
Symptoms are often acute and severe
Oesophageal damage can be prevented
References

Dose form may not be a contributing factor

CARM has received a total of 56 reports of oesophagitis associated with antibiotics; of these, 46 were for doxycycline.  In Australia, there have been 46 reports of oesophagitis and 49 reports of oesophageal ulceration received in total, all with doxycycline. It is unclear whether these events are more likely to occur with a particular dose form (i.e. tablets or capsules), as the brands most commonly used in Australia are available only in tablet formulations.¹  However, doxycycline capsules frequently remain in contact with the oesophagus for longer periods than the tablet form.²

Many other medicines are known to cause oesophagitis

Oesophageal damage occurs when a medicine lingers in the oesophagus long enough to cause mucosal lesions.  This can arise when little or no fluid is taken to assist swallowing of the medicine and facilitation of its subsequent passage through the oesophagus into the stomach.  Damage can also occur, probably from reflux, if the patient lies down soon after taking the medicine.  Ulcers may be seen endoscopically.  At least 70 different medicines have been reported to cause oesophageal disorders.  Antibacterials such as clindamycin, doxycycline, minocycline and tetracycline are the most commonly implicated agents.  Other medicines include alendronate, aspirin, ferrous sulphate, non-steroidal anti-inflammatory agents, potassium chloride and quinidine.²

Symptoms are often acute and severe

In most cases, there are no patient-related predisposing factors other than poor swallowing technique (i.e. insufficient fluid intake or not remaining upright).  The symptoms of doxycycline-induced oesophagitis include sudden onset of pain on swallowing and often very severe chest pain.  A temporal relationship between onset of symptoms and ingestion of doxycycline should be considered as part of the diagnosis.  In most cases, cessation of the causative agent is sufficient for symptoms to resolve.²  Recovery may take longer than two weeks in severe cases.³  Symptomatic use of a proton pump inhibitor for 1-2 weeks may be required.  However, endoscopy is not usually necessary and can be extremely uncomfortable for the patient.

Oesophageal damage can be prevented

Prescribers and pharmacists are reminded that the risk of this adverse effect can be minimised, or even avoided, by advising patients to take every dose of doxycycline (and other implicated medicines) either with food or a large glass of water, and to remain sitting upright or standing for at least 30 minutes (and up to 2 hours⁴) afterwards.³

Competing interests (authors): none declared.

References

1. Personal communication, 29 August 2003. Executive Officer, Adverse Drug Reactions Unit, Therapeutic Goods Administration, Australia.
2. Jaspersen D. Drug-induced oesophageal disorders - pathogenesis, incidence, prevention and management. Drug Safety 2000;22(3):237-249.
3. Medsafe Editorial Team. Doxycycline and oesophageal ulceration. Prescriber Update February 2000;(19):33-34. www.medsafe.govt.nz/profs/PUarticles/doxyou.htm
4. Pacific Pharmaceuticals Ltd. Doxine data sheet August 2000. www.medsafe.govt.nz/
   profs/Datasheet/d/Doxinetab.pdf