Adverse effects
Adverse effects are typically mild to moderate. However, severe, disabling, and potentially irreversible adverse effects sometimes occur, and for this reason it is recommended that use of fluoroquinolones be limited.
Prominent among these are adverse effects that became the subject of a black box warning by the FDA in 2016.[40] The FDA wrote: "An FDA safety review has shown that fluoroquinolones when used systemically (i.e. tablets, capsules, and injectable) are associated with disabling and potentially permanent serious adverse effects that can occur together. These adverse effects can involve the tendons, muscles, joints, nerves, and central nervous system."[40] Rarely, tendinitis or tendon rupture may occur due to fluoroquinolone antibiotics, including levofloxacin.[41] Such injuries, including tendon rupture, has been observed up to six months after cessation of treatment; higher doses of fluoroquinolones, being elderly, transplant patients, and those with a current or historical corticosteroid use are at elevated risk.[42][43] The US label for levofloxacin also contains a black box warning for the exacerbation of the symptoms of the neurological disease myasthenia gravis.[44] Similarly, the UK Medicines and Healthcare Products Regulatory Agency recommendations warn of rare but disabling and potentially irreversible adverse effects, and to recommend limiting use of these drugs.[45] Increasing age and corticosteroid use appears to increase the risk of musculoskeletal complications.[39]
A wide variety of other uncommon but serious adverse events have been associated with fluoroquinolone use, with varying degrees of evidence supporting causation. These include anaphylaxis, hepatotoxicity, central nervous system effects including seizures and psychiatric effects, prolongation of the QT interval, blood glucose disturbances, and photosensitivity, among others.[33] Levofloxacin may produce fewer of these rare serious adverse effects than other fluoroquinolones.[46]
There is some disagreement in the medical literature regarding whether and to what extent levofloxacin and other fluoroquinolones produce serious adverse effects more frequently than other broad spectrum antibacterial drugs.[47][48][49][50]
Concerning more usual adverse effects, in pooled results from 7537 patients exposed to levofloxacin in 29 clinical trials, 4.3% discontinued treatment due to adverse drug reactions. The most common adverse reactions leading to discontinuation were gastrointestinal, including nausea, vomiting, and constipation. Overall, 7% of patients experienced nausea, 6% headache, 5% diarrhea, and 4% insomnia, along with other adverse reactions experienced at lower rates.[51]
Administration of levofloxacin or other broad-spectrum antibiotics is associated with Clostridioides difficile associated diarrhea which may range in severity from mild diarrhea to fatal colitis. Fluoroquinolone administration may be associated with the acquisition and outgrowth of a particularly virulent Clostridioides strain.[52]
More research is needed to determine the best dose and length of treatment.[53]
