Fluoroquinolones and Aortic Dissection - Again

Written by Clay Smith

Spoon Feed
Use of fluoroquinolones (FQ) was associated with a 2.5-fold increase in risk of hospitalization for aortic aneurysm (AA) or aortic dissection (AD).

Why does this matter?
Fluoroquinolones are known to have effects on connective tissue. A prior study in BMJ showed increased risk of aortic dissection in patients with recent use. These drugs can chelate ions involved in type 1 collagen synthesis and reduce expression of metalloproteinases. So, it’s plausible that they could increase risk for aortic aneurysm or dissection.

Take this pill, and your aorta explodes.
This was a unique case-crossover and case-time-design approach from a detailed Taiwanese nationwide database (see figure). They identified 1,213 inpatient cases of aortic aneurysm (AA) or aortic dissection (AD) from 2000-2011. Unlike the usual case-control, in the case-crossover the patient acted as his or her own control for the 60-day time period just before the AA/AD event compared to an earlier 60-day earlier time period. They hypothesized that the odds of exposure to a FQ in the 60-days prior to the AA/AD event would be greater than the odds of exposure in a randomly selected prior 60-day period. Turns out, that was correct. In the 60-day period just before the AA/AD event, 1.6% of patients were taking a FQ compared to just 0.6% in a random 60-day prior period of time, which means a 270% greater odds of taking a FQ just prior to their aorta exploding, (odds ratio 2.71; 95%CI 1.14–6.46). They performed additional analysis to make sure the increase in FQ use wasn’t confounded by a general population trend of increased FQ use. It wasn’t. They also found the longer the duration of FQ treatment, the greater the risk. Assuming this association is correct, the authors estimate the number needed to harm to be about 10,000. With over 25 million prescriptions for FQ in the US in 2012, that would mean an additional 2,500 cases per year of AA or AD. They estimated a NNH of around 500 in patients >65.

Another Spoonful
EMLoN reviewed this and thinks the association is probably real.

 From cited article

From cited article

Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067.

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