Medications to avoid with Ehlers-Danlos Syndrome: Fluoroquinolones

Fluoroquinolones are a class of antibiotics commonly prescribed to treat various bacterial infections. While effective in combating infections, they are also associated with severe side effects, particularly for individuals with connective tissue disorders such as Ehlers-Danlos Syndrome (EDS), Marfan Syndrome, and Loeys-Dietz Syndrome. Given the complexities of connective tissue disorders, it's crucial to understand the implications of using fluoroquinolones.

What Are Fluoroquinolones?

Fluoroquinolones include antibiotics such as:

• Ciprofloxacin (Cipro)
• Levofloxacin (Levaquin)
• Moxifloxacin (Avelox)
• Ofloxacin (Floxin)
• Gemifloxacin (Factive)
• Norfloxacin (Noroxin)

These medications are often prescribed for respiratory infections, urinary tract infections, and certain skin infections.

Risks of Fluoroquinolones

The use of fluoroquinolones has been linked to various adverse effects, particularly related to the musculoskeletal system and connective tissues. These antibiotics can cause tendonitis, tendon rupture, and potentially life-threatening conditions such as aortic aneurysm and dissection. This is especially concerning for individuals with underlying connective tissue disorders.

Some specific risks associated with fluoroquinolones include:

1. Tendon Rupture and Tendonitis: Fluoroquinolones have long been associated with tendon damage, particularly in the Achilles tendon. This risk is heightened in those over 60 years old, people on corticosteroids, and individuals with connective tissue disorders​​.
2. Aortic Aneurysm and Dissection: Recent research indicates that fluoroquinolones may increase the risk of aortic aneurysm or dissection. The FDA has issued warnings about this risk, especially in individuals with Marfan Syndrome, EDS, Loeys-Dietz Syndrome, or a history of vascular diseases​​​.
3. Musculoskeletal Damage: A study in 2021 showed that fluoroquinolones are linked to disabling and potentially permanent musculoskeletal damage, especially in the joints, muscles, and connective tissues, which are already vulnerable in EDS and other connective tissue disorders​.
4. Neurological Issues: Fluoroquinolones have also been associated with peripheral neuropathy, which can cause tingling, numbness, and long-term nerve damage. Individuals with EDS often experience neurological symptoms, and the use of these antibiotics can exacerbate such conditions​.
5. Other Side Effects: Fluoroquinolones can cause low blood sugar levels, mental health issues (including delirium and confusion), and gastrointestinal problems​​. These effects can be particularly dangerous for individuals with autonomic dysfunction or gastrointestinal issues, which are common in EDS​​.

Connective Tissue Disorders Affected by Fluoroquinolones

People with the following connective tissue disorders are at increased risk when taking fluoroquinolones:

• Ehlers-Danlos Syndrome (EDS), particularly the vascular type (vEDS), where there is a higher risk of arterial and organ rupture​.
• Marfan Syndrome, where the structural weakness of the aorta makes individuals prone to aneurysm and dissection​​.
• Loeys-Dietz Syndrome, another connective tissue disorder involving a high risk of aortic rupture​.

Evidence Supporting the Risks

The FDA has issued multiple warnings about fluoroquinolones over the years, including a 2018 safety update specifically highlighting the increased risk of aortic tears and ruptures in susceptible patients​​. Several studies support these findings, showing that people taking fluoroquinolones are twice as likely to suffer from aortic aneurysm or dissection​​.

FDA Recommendations

The FDA advises against using fluoroquinolones in patients with a history of aortic aneurysm, vascular diseases, or genetic conditions such as EDS and Marfan Syndrome, unless no other treatment options are available​​. Healthcare professionals are encouraged to prescribe alternative antibiotics whenever possible for individuals with these risk factors.

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FAQ

1. What antibiotics should people with EDS avoid?

• People with EDS should avoid fluoroquinolones, as these antibiotics are associated with increased risks of tendon damage, aortic aneurysm, and dissection.

2. Is Cipro bad for Ehlers-Danlos?

• Yes, Cipro (ciprofloxacin) is a fluoroquinolone that has been shown to increase the risk of tendon rupture and aortic complications, making it particularly risky for individuals with EDS​​.

3. What medications should be avoided with hypermobile Ehlers-Danlos Syndrome (hEDS)?

• In addition to fluoroquinolones, medications like systemic corticosteroids and other drugs that can weaken connective tissues should be used cautiously in hEDS​​.

4. Who should not take fluoroquinolones?

• Fluoroquinolones should not be used by individuals with connective tissue disorders (like EDS or Marfan Syndrome), those with a history of aortic aneurysm, the elderly, and people on corticosteroid therapy​​.

5. What to avoid with Ehlers-Danlos?

• People with EDS should avoid activities and medications that can strain or damage their connective tissues, such as high-impact exercises, fluoroquinolones, and steroid overuse​.

6. What is the dark side of Cipro?

• The "dark side" of Cipro refers to its potential for severe side effects, including tendon rupture, aortic dissection, nerve damage, and mental health issues​​.

7. What is the black box warning for fluoroquinolones?

• The black box warning for fluoroquinolones highlights risks of tendonitis, tendon rupture, peripheral neuropathy, and central nervous system effects​​.

8. Can fluoroquinolones cause tendon rupture risk?

• Yes, fluoroquinolones are known to increase the risk of tendon rupture, particularly in the Achilles tendon, and especially in older adults or those on corticosteroids​​.

9. Why do doctors not prescribe ciprofloxacin?

• Due to its severe side effects, many doctors avoid prescribing ciprofloxacin unless absolutely necessary, especially for patients at risk of tendon and vascular complications​.

10. Why is Cipro not recommended for people over 60?

• Cipro is not recommended for older adults because they are at higher risk of tendon rupture, aortic aneurysm, and other severe side effects​.

11. Why avoid Cipro?

• Cipro should be avoided due to its association with disabling side effects like tendon damage, nerve issues, and vascular problems, which can be particularly dangerous for certain populations​​.

By staying informed about the risks of fluoroquinolones, patients and healthcare providers can make safer choices regarding antibiotic use, especially for individuals with EDS and other connective tissue disorders.

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References

• U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA Advises Restricting Fluoroquinolone Antibiotic Use for Certain Uncomplicated Infections; Warns About Disabling Side Effects That Can Occur Together. 12 May 2016. https://www.fda.gov/Drugs/DrugSafety/ucm500143.htm. Accessed 2024.
• U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA Updates Warnings for Oral and Injectable Fluoroquinolone Antibiotics Due to Disabling Side Effects. 26 July 2016. https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm. Accessed 2024.
• U.S. Food and Drug Administration. FDA Reinforces Safety Information About Serious Low Blood Sugar Levels and Mental Health Side Effects with Fluoroquinolone Antibiotics; Requires Label Changes. 10 July 2018. https://www.fda.gov/Drugs/DrugSafety/ucm618141.htm. Accessed 2024.
• U.S. Food and Drug Administration. FDA Warns About Increased Risk of Ruptures or Tears in the Aorta Blood Vessel with Fluoroquinolone Antibiotics in Certain Patients. 20 Dec. 2018. https://www.fda.gov/Drugs/DrugSafety/ucm611032.htm. Accessed 2024.
• Huruba, Madalina, et al. "A VigiBase Descriptive Study of Fluoroquinolone-Induced Disabling and Potentially Permanent Musculoskeletal and Connective Tissue Disorders." Scientific Reports, vol. 11, 2021, p. 14375, https://doi.org/10.1038/s41598-021-93763-y.
• Demetrious, James S. "Spontaneous Cervical Artery Dissection: A Fluoroquinolone-Induced Connective Tissue Disorder?" Chiropractic & Manual Therapies, vol. 26, 2018, p. 22, https://doi.org/10.1186/s12998-018-0193-z.
• Marchant, Jo. "When Antibiotics Turn Toxic." Nature, vol. 555, 22 Mar. 2018, pp. 431-432.

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