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Aortic aneurysm: Fluoroquinolones, genetic counseling, June 2018

Mark R. Goldstein, MD, FACP and Luca Mascitelli, MD
Cleveland Clinic Journal of Medicine September 2018, 85 (9) 661; DOI: https://doi.org/10.3949/ccjm.85c.09001
Mark R. Goldstein
NCH Physician Group, Center for Healthy Living, Naples, FL
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Luca Mascitelli
Comando Brigata Alpina “Julia”/Multinational Land Force, Medical Service, Udine, Italy
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TO THE EDITOR: We read with interest the article by Cikach et al on thoracic aortic aneurysm.1 For medical management of this condition, the authors emphasized controlling blood pressure and heart rate and also avoiding isometric exercises and heavy lifting. In addition to their recommendations, we believe there is plausible evidence to advise caution if fluoroquinolone antibiotics are used in this setting.

Three large population-based studies, from Canada,2 Taiwan,3 and Sweden,4 collectively demonstrated a significant 2-fold increase in the incidence of aortic aneurysm and dissection presenting within 60 days of fluoroquinolone use compared with other antibiotic exposure. Moreover, a longer duration of fluoroquinolone use was associated with a significantly higher incidence of aortic aneurysm and dissection.3

Mechanistically, fluoroquinolones have been shown to up-regulate production of several matrix metalloproteinases, including metalloproteinase 2, leading to degradation of type I collagen.2,5 Type I and type III are the dominant collagens in the aortic wall, and collagen degradation is implicated in aortic aneurysm formation and expansion.

Fluoroquinolones are widely prescribed in both outpatient and inpatient settings and are sometimes used for long durations in the geriatric population.2 It is possible that these drugs have a propensity to increase aortic aneurysm expansion and dissection in older patients who already have aortic aneurysm. Accordingly, this might make the risk-benefit ratio unfavorable for using these drugs in these situations, and other antibiotics should be used, if indicated.

Furthermore, if fluoroquinolones are used in patients with aortic aneurysm, perhaps imaging studies of the aneurysm should be done more frequently than once a year to detect accelerated aneurysm growth. Finally, physicians should be aware of the possibility of increased aortic aneurysm expansion and dissection with fluoroquinolone use.

  • Copyright © 2018 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

  1. ↵
    1. Cikach F,
    2. Desai MY,
    3. Roselli EE,
    4. Kalahasti V
    . Thoracic aortic aneurysm: how to counsel, when to refer. Cleve Clin J Med 2018; 85(6):481–492. doi:10.3949/ccjm.85a.17039
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Daneman N,
    2. Lu H,
    3. Redelmeier DA
    . Fluoroquinolones and collagen associated severe adverse events: a longitudinal cohort study. BMJ Open 2015; 5:e010077. doi:10.1136/bmjopen-2015-010077
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Lee C-C,
    2. Lee MG,
    3. Chen Y-S,
    4. et al
    . Risk of aortic dissection and aortic aneurysm in patients taking oral fluoroquinolone. JAMA Intern Med 2015; 175:1839–1847. doi:10.1001/jamainternmed.2015.5389
    OpenUrlCrossRef
  4. ↵
    1. Pasternak B,
    2. Inghammar M,
    3. Svanström H
    . Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ Open 2018; 360:k678. doi:10.1136/bmj.k678
    OpenUrlCrossRef
  5. ↵
    1. Tsai W-C,
    2. Hsu C-C,
    3. Chen CPC,
    4. et al
    . Ciprofloxacin up-regulates tendon cells to express matrix metalloprotein-ase-2 with degradation of type I collagen. J Orthop Res 2011; 29(1):67–73. doi:10.1002/jor.21196
    OpenUrlCrossRefPubMed
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Cleveland Clinic Journal of Medicine: 85 (9)
Cleveland Clinic Journal of Medicine
Vol. 85, Issue 9
1 Sep 2018
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Aortic aneurysm: Fluoroquinolones, genetic counseling, June 2018
Mark R. Goldstein, Luca Mascitelli
Cleveland Clinic Journal of Medicine Sep 2018, 85 (9) 661; DOI: 10.3949/ccjm.85c.09001

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Aortic aneurysm: Fluoroquinolones, genetic counseling, June 2018
Mark R. Goldstein, Luca Mascitelli
Cleveland Clinic Journal of Medicine Sep 2018, 85 (9) 661; DOI: 10.3949/ccjm.85c.09001
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