A 80-year-old male patient started treatment with Ciproxin (ciprofloxacin) 0.5 gram x2 on the 19th

Fråga: A 80-year-old male patient started treatment with Ciproxin (ciprofloxacin) 0.5 gram x2 on the 19th of July because of epididymitis. He had a grand mal seizure on the 21st of July. He has no known epilepsy. Can ciprofloxacin give rise to such a reaction? The patient has no known kidney disease. Serum creatinine was 82 umol/l.

Sammanfattning: Rarely, seizures or convulsions have been reported to occur during treatment with ciprofloxacin. A few cases are described in the literature. In some of these cases kidney function has been decreased or there has been a concomitant therapy with theophylline.

Svar: Ciprofloxacin is an oral fluoroquinolone which structurally resembles nalidixic acid. It is eliminated predominantly by renal excretion and dose adjustment is recommended for patients with renal impairment.

The most frequent adverse effects are of the gastrointestinal type. Convulsive seizures have rarely been reported to occur with ciprofloxacin or other quinolone agents. In some of these cases the seizures may have been caused by altered pharmacokinetics and pharmacodynamics brought about by combined therapy with theophylline and ciprofloxacin (1,2) or by an underlying seizure disorder.

One case describes a 74-year-old woman with multiple medical problems including chronic renal failure. Twelve days after treatment with ciprofloxacin and metronidazole the patient experienced generalized myoclonus and muscle twitching. Although the patient received the usual dose, it was excessive for her degree of kidney function and this was thought to be the likely cause of her neurotoxicity (3). This case was commented on as the patient also received meperidine and other authors believed that meperidine was more likely to have caused neurotoxicity (4). The main author (3) persisted in the belief that ciprofloxacin was the causative factor. A letter to the editor (5) refers to three cases of seizures beginning shortly after starting ciprofloxacin therapy. One of the patients had grand mal epilepsy but had been seizure free for at least ten years. He took phenytoin as the only medication. One patient had known brain damage. The third patient had a grand mal seizure eight hours after receiving a 500 mg dose of ciprofloxacin.

Two cases of convulsions and one case of aggravated epilepsy have been reported to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC) in connection with ciprofloxacin. The WHO have received in total 905 reports of ciprofloxacin and neurotoxicity. Among these are two cases of aggravated convulsion, 52 cases of grand mal convulsions, 108 cases of headache, 19 cases of involuntary muscle contractions and 58 cases of paraesthesia. One must bear in mind however that these cases have been classified as either probable or possible or just as events with no clear relationship to the drug. Different countries have different ways of registering adverse effects in connection with drug use. We suggest that this case be reported to SADRAC.