Limits...
Moxifloxacin safety: an analysis of 14 years of clinical data.

Tulkens PM, Arvis P, Kruesmann F - Drugs R D (2012)

Bottom Line: Analysis by comparator (including another fluoroquinolone) did not reveal medically relevant differences, even in patients at risk.Incidence rates of hepatic disorders, tendon disorders, clinical surrogates of QT prolongation, serious cutaneous reactions, and Clostridium difficile-associated diarrhea were similar with moxifloxacin and comparators.The safety of moxifloxacin is essentially comparable to that of standard therapies for patients receiving the currently registered dosage and for whom contraindications and precautions of use (as in the product label) are taken into account.

View Article: PubMed Central - PubMed

Affiliation: Pharmacologie cellulaire et molculaire Centre de Pharmacie clinique, Louvain Drug Research Institute, Universit catholique de Louvain, Brussels, Belgium. tulkens@facm.ucl.ac.be

ABSTRACT

Background: Moxifloxacin, a fluoroquinolone antibiotic, is used for the treatment of respiratory tract, pelvic inflammatory disease, skin, and intra-abdominal infections. Its safety profile is considered favorable in most reviews but has been challenged with respect to rare but potentially fatal toxicities (e.g. hepatic, cardiac, or skin reactions).

Objective: To analyze and compare the safety profile of moxifloxacin versus comparators in the entire clinical database of the manufacturer.

Setting: Data on the valid-for-safety population from phase II-IV actively controlled studies (performed between 1996 and 2010) were analyzed. Studies were either double blind (n = 22 369) or open label (n = 7635) and included patients with indications that have been approved in at least one country [acute bacterial sinusitis, acute exacerbation of chronic bronchitis, community-acquired pneumonia, uncomplicated pelvic inflammatory disease, complicated and uncomplicated skin and skin structure infections, and complicated intra-abdominal infections] (n = 27 824) and patients with other indications (n = 2180), using the recommended daily dose (400 mg) and route of administration (oral, intravenous/oral, intravenous only). The analysis included patients at risk (age ≥65 years, diabetes mellitus, renal impairment, hepatic impairment, cardiac disorders, or body mass index <18 kg/m2). Patients with known contraindications were excluded from enrollment by study protocol design, but any patient having entered a study, even if inappropriately, was included in the analysis.

Main outcome measure: Crude incidences and relative risk estimates (Mantel-Haenszel analysis) of patients with any adverse event (AE), adverse drug reaction (ADR), serious AE (SAE), serious ADR (SADR), treatment discontinuation due to an AE or ADR, and fatal outcomes related to an AE or ADR.

Results: Overall incidence rates of AEs were globally similar in the moxifloxacin and comparator groups. By filtering the data for differences in disfavor of moxifloxacin (i) at ≥2.5% for events with an incidence ≥2.5% or at ≥2-fold for events with an incidence <2.5% in one or both groups and (ii) affecting ≥10 patients in either group, we observed slightly more (i) AEs in double-blind intravenous-only and open-label oral studies, (ii) SAEs in double-blind intravenous-only studies, (iii) ADRs and SADRs in open-label oral studies, (iv) SADRs in open-label intravenous/oral studies, and (v) premature discontinuation due to AEs in open-label intravenous-only studies. The actual numbers of SADRs (in all studies) were small, with clinically relevant differences noted only in intravenous/oral studies and mainly driven by 'gastrointestinal disorders' (15 versus 7 patients) and 'changes observed during investigations' (23 versus 7 patients [asymptomatic QT prolongation: 11 versus 4 patients in double-blind studies]). Analysis by comparator (including another fluoroquinolone) did not reveal medically relevant differences, even in patients at risk. Incidence rates of hepatic disorders, tendon disorders, clinical surrogates of QT prolongation, serious cutaneous reactions, and Clostridium difficile-associated diarrhea were similar with moxifloxacin and comparators.

Conclusion: The safety of moxifloxacin is essentially comparable to that of standard therapies for patients receiving the currently registered dosage and for whom contraindications and precautions of use (as in the product label) are taken into account.

Show MeSH

Related in: MedlinePlus

Incidence of adverse events, adverse drug reactions, serious adverse events, serious adverse drug reactions, discontinuation due to adverse events, discontinuation due to adverse drug reactions, adverse events with fatal outcome, and adverse drug reactions with fatal outcome in patients with risk factors (age, diabetes mellitus, renal or hepatic impairment, cardiac disorder, low body mass index) treated with moxifloxacin or a comparator and stratified by route of administration (oral only; intravenous followed by oral [sequential]; intravenous only) and by study design
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC3585838&req=5

Tab8: Incidence of adverse events, adverse drug reactions, serious adverse events, serious adverse drug reactions, discontinuation due to adverse events, discontinuation due to adverse drug reactions, adverse events with fatal outcome, and adverse drug reactions with fatal outcome in patients with risk factors (age, diabetes mellitus, renal or hepatic impairment, cardiac disorder, low body mass index) treated with moxifloxacin or a comparator and stratified by route of administration (oral only; intravenous followed by oral [sequential]; intravenous only) and by study design

Mentions: Because the safety of drugs can be adversely influenced by the patient status and may also worsen it, data were also stratified according to the main pertinent co-morbidities and elimination pathway disorders observed in the population – namely age, diabetes mellitus, renal impairment, hepatic impairment, cardiac disorders, and abnormally low BMI. First, patients were stratified by study design (double blind and open label) and administration route (oral, intravenous/oral, intravenous), and the results are presented in table VIII. To better apprehend potentially meaningful differences, relative risk estimates (moxifloxacin versus comparator) were then calculated for each patient group stratified according to the administration route. The results are presented graphically in figures 2 and 3. On the basis of a threshold of a 2–fold increase in risk estimates, the only difference seen in patients receiving oral treatment was in those with underlying cardiac disorders (more AEs with fatal outcome for comparator) [figure 3b]; and the only differences seen in those receiving intravenous treatment were in those with (i) age ≥65 years (more ADRs with fatal outcome for comparator [figure 2a]); (ii) diabetes mellitus (more discontinuations due to ADRs for comparator [figure 2b]); (iii) hepatic impairment (more SADRs, discontinuation due to ADRs, and AEs with fatal outcome for moxifloxacin [figure 3a]); (iv) cardiac disorders (more discontinuations due to AEs for moxifloxacin and more ADRs with fatal outcome for comparator [figure 3b]); and (v) BMI <18 kg/m2 (more discontinuations due to AEs or ADRs, and more AEs with fatal outcome for moxifloxacin [figure 3c]). However, numbers in the intravenous-only studies were small in all cases (1–7 patients). Lastly, the relative risk estimates (moxifloxacin versus comparator) were calculated after substratifying each group according to the comparator used, concentrating for each comparator on patients treated by the most frequent route of administration (if versus a β-lactam: oral, intravenous/oral and intravenous; if versus a macrolide alone: oral; if versus a β-lactam alone or a beta-lactam combined with a macrolide: intravenous/oral; if versus fluoroquinolone: intravenous only). The results are shown graphically in figures 4–6. Concentrating again on differences in disfavor of moxifloxacin, a >2-fold difference in disfavor of moxifloxacin in at least one safety variable was observed for patients with (i) age ≥65 years (intravenous/oral versus β-lactam alone or versus β-lactam ± macrolide [figure 5a or 5b]); (ii) diabetes mellitus (intravenous/oral versus β-lactam alone or versus β-lactam ± macrolide [figure 5a or 5b]); (iii) renal impairment (intravenous/oral versus β-lactam ± macrolide [figure 5b], and intravenous versus β-lactam [figure 6a]); (iv) hepatic impairment (oral versus β-lactam [figure 4a], and intravenous versus β-lactam or versus another fluoroquinolone [figure 6a or 6b]); (v) cardiac disorders (intravenous versus β-lactam [figure 6a]); and (vi) BMI <18 kg/m2 (oral versus β-lactam [figure 4a] and intravenous versus β-lactam or versus another fluoroquinolone [figure 6a or 6b]). However, the numbers of patients with events were very small in all cases (1–24).


Moxifloxacin safety: an analysis of 14 years of clinical data.

Tulkens PM, Arvis P, Kruesmann F - Drugs R D (2012)

Incidence of adverse events, adverse drug reactions, serious adverse events, serious adverse drug reactions, discontinuation due to adverse events, discontinuation due to adverse drug reactions, adverse events with fatal outcome, and adverse drug reactions with fatal outcome in patients with risk factors (age, diabetes mellitus, renal or hepatic impairment, cardiac disorder, low body mass index) treated with moxifloxacin or a comparator and stratified by route of administration (oral only; intravenous followed by oral [sequential]; intravenous only) and by study design
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3585838&req=5

Tab8: Incidence of adverse events, adverse drug reactions, serious adverse events, serious adverse drug reactions, discontinuation due to adverse events, discontinuation due to adverse drug reactions, adverse events with fatal outcome, and adverse drug reactions with fatal outcome in patients with risk factors (age, diabetes mellitus, renal or hepatic impairment, cardiac disorder, low body mass index) treated with moxifloxacin or a comparator and stratified by route of administration (oral only; intravenous followed by oral [sequential]; intravenous only) and by study design
Mentions: Because the safety of drugs can be adversely influenced by the patient status and may also worsen it, data were also stratified according to the main pertinent co-morbidities and elimination pathway disorders observed in the population – namely age, diabetes mellitus, renal impairment, hepatic impairment, cardiac disorders, and abnormally low BMI. First, patients were stratified by study design (double blind and open label) and administration route (oral, intravenous/oral, intravenous), and the results are presented in table VIII. To better apprehend potentially meaningful differences, relative risk estimates (moxifloxacin versus comparator) were then calculated for each patient group stratified according to the administration route. The results are presented graphically in figures 2 and 3. On the basis of a threshold of a 2–fold increase in risk estimates, the only difference seen in patients receiving oral treatment was in those with underlying cardiac disorders (more AEs with fatal outcome for comparator) [figure 3b]; and the only differences seen in those receiving intravenous treatment were in those with (i) age ≥65 years (more ADRs with fatal outcome for comparator [figure 2a]); (ii) diabetes mellitus (more discontinuations due to ADRs for comparator [figure 2b]); (iii) hepatic impairment (more SADRs, discontinuation due to ADRs, and AEs with fatal outcome for moxifloxacin [figure 3a]); (iv) cardiac disorders (more discontinuations due to AEs for moxifloxacin and more ADRs with fatal outcome for comparator [figure 3b]); and (v) BMI <18 kg/m2 (more discontinuations due to AEs or ADRs, and more AEs with fatal outcome for moxifloxacin [figure 3c]). However, numbers in the intravenous-only studies were small in all cases (1–7 patients). Lastly, the relative risk estimates (moxifloxacin versus comparator) were calculated after substratifying each group according to the comparator used, concentrating for each comparator on patients treated by the most frequent route of administration (if versus a β-lactam: oral, intravenous/oral and intravenous; if versus a macrolide alone: oral; if versus a β-lactam alone or a beta-lactam combined with a macrolide: intravenous/oral; if versus fluoroquinolone: intravenous only). The results are shown graphically in figures 4–6. Concentrating again on differences in disfavor of moxifloxacin, a >2-fold difference in disfavor of moxifloxacin in at least one safety variable was observed for patients with (i) age ≥65 years (intravenous/oral versus β-lactam alone or versus β-lactam ± macrolide [figure 5a or 5b]); (ii) diabetes mellitus (intravenous/oral versus β-lactam alone or versus β-lactam ± macrolide [figure 5a or 5b]); (iii) renal impairment (intravenous/oral versus β-lactam ± macrolide [figure 5b], and intravenous versus β-lactam [figure 6a]); (iv) hepatic impairment (oral versus β-lactam [figure 4a], and intravenous versus β-lactam or versus another fluoroquinolone [figure 6a or 6b]); (v) cardiac disorders (intravenous versus β-lactam [figure 6a]); and (vi) BMI <18 kg/m2 (oral versus β-lactam [figure 4a] and intravenous versus β-lactam or versus another fluoroquinolone [figure 6a or 6b]). However, the numbers of patients with events were very small in all cases (1–24).

Bottom Line: Analysis by comparator (including another fluoroquinolone) did not reveal medically relevant differences, even in patients at risk.Incidence rates of hepatic disorders, tendon disorders, clinical surrogates of QT prolongation, serious cutaneous reactions, and Clostridium difficile-associated diarrhea were similar with moxifloxacin and comparators.The safety of moxifloxacin is essentially comparable to that of standard therapies for patients receiving the currently registered dosage and for whom contraindications and precautions of use (as in the product label) are taken into account.

View Article: PubMed Central - PubMed

Affiliation: Pharmacologie cellulaire et molculaire Centre de Pharmacie clinique, Louvain Drug Research Institute, Universit catholique de Louvain, Brussels, Belgium. tulkens@facm.ucl.ac.be

ABSTRACT

Background: Moxifloxacin, a fluoroquinolone antibiotic, is used for the treatment of respiratory tract, pelvic inflammatory disease, skin, and intra-abdominal infections. Its safety profile is considered favorable in most reviews but has been challenged with respect to rare but potentially fatal toxicities (e.g. hepatic, cardiac, or skin reactions).

Objective: To analyze and compare the safety profile of moxifloxacin versus comparators in the entire clinical database of the manufacturer.

Setting: Data on the valid-for-safety population from phase II-IV actively controlled studies (performed between 1996 and 2010) were analyzed. Studies were either double blind (n = 22 369) or open label (n = 7635) and included patients with indications that have been approved in at least one country [acute bacterial sinusitis, acute exacerbation of chronic bronchitis, community-acquired pneumonia, uncomplicated pelvic inflammatory disease, complicated and uncomplicated skin and skin structure infections, and complicated intra-abdominal infections] (n = 27 824) and patients with other indications (n = 2180), using the recommended daily dose (400 mg) and route of administration (oral, intravenous/oral, intravenous only). The analysis included patients at risk (age ≥65 years, diabetes mellitus, renal impairment, hepatic impairment, cardiac disorders, or body mass index <18 kg/m2). Patients with known contraindications were excluded from enrollment by study protocol design, but any patient having entered a study, even if inappropriately, was included in the analysis.

Main outcome measure: Crude incidences and relative risk estimates (Mantel-Haenszel analysis) of patients with any adverse event (AE), adverse drug reaction (ADR), serious AE (SAE), serious ADR (SADR), treatment discontinuation due to an AE or ADR, and fatal outcomes related to an AE or ADR.

Results: Overall incidence rates of AEs were globally similar in the moxifloxacin and comparator groups. By filtering the data for differences in disfavor of moxifloxacin (i) at ≥2.5% for events with an incidence ≥2.5% or at ≥2-fold for events with an incidence <2.5% in one or both groups and (ii) affecting ≥10 patients in either group, we observed slightly more (i) AEs in double-blind intravenous-only and open-label oral studies, (ii) SAEs in double-blind intravenous-only studies, (iii) ADRs and SADRs in open-label oral studies, (iv) SADRs in open-label intravenous/oral studies, and (v) premature discontinuation due to AEs in open-label intravenous-only studies. The actual numbers of SADRs (in all studies) were small, with clinically relevant differences noted only in intravenous/oral studies and mainly driven by 'gastrointestinal disorders' (15 versus 7 patients) and 'changes observed during investigations' (23 versus 7 patients [asymptomatic QT prolongation: 11 versus 4 patients in double-blind studies]). Analysis by comparator (including another fluoroquinolone) did not reveal medically relevant differences, even in patients at risk. Incidence rates of hepatic disorders, tendon disorders, clinical surrogates of QT prolongation, serious cutaneous reactions, and Clostridium difficile-associated diarrhea were similar with moxifloxacin and comparators.

Conclusion: The safety of moxifloxacin is essentially comparable to that of standard therapies for patients receiving the currently registered dosage and for whom contraindications and precautions of use (as in the product label) are taken into account.

Show MeSH
Related in: MedlinePlus