Confusion about stopping cipro due to myasthesia gravis

[shahj3]

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So, I had a patient's wife who called the pharmacy in the evening and said that her husband was prescribed ciprofloxacin. Before giving him the medicine, she read in the package insert that cipro should not be given to someone with myasthesia gravis. She asked if her husband should not take this medicine due to that. He just developed this problem 2-3 weeks ago. She said he was feeling fine that day, with respect to his infection. I told him to not take the cipro that night and call the MD 1st thing in the morning. Do you think that was the right thing to do? Would you have handled it any differently?

 

[Notecard]

It's part of the BB warning. I'm just a P2 but pretty sure that's the call we would have made too.

 

[amox]

Exacerbations of myasthenia gravis (< 1%) have been noted with ciprofloxacin use (see Contraindications). Serious post-marketing reports of myasthenia gravis exacerbations, including deaths and the requirement for ventilatory support, have been associated with systemic quinolone use.

Source : Clinical Pharmacology

Fluoroquinolones, including ciprofloxacin, may exacerbate muscle weakness in persons with myasthenia gravis. Avoid in patients with known history of myasthenia gravis

Source : Micromedex

So less than 1% of myasthenia gravis patients experience side effects, however it is so severe that it is not recommended.

Call MD and have them change the quinolone to another class. You did the right thing in my opinion.

 

[All4MyDaughter]

I would have asked if the physician who prescribed the ciprofloxacin was aware of the patients MG diagnosis and then called/faxed the office to make sure. And, I would have noted the patient's status on his profile so that any future drug/disease interactions would flag.

 

[shahj3]

Thanks for your reply everyone! That's a good point All4MyDaughter. It was late in the evening when I got the call, so I couldn't contact the MD. However, I should have asked the patient if the MD knew he had myasthenia gravis and should have marked it in the computer. That's good advice. Thanks!

 

[All4MyDaughter]

Thanks for your reply everyone! That's a good point All4MyDaughter. It was late in the evening when I got the call, so I couldn't contact the MD. However, I should have asked the patient if the MD knew he had myasthenia gravis and should have marked it in the computer. That's good advice. Thanks!

If I'm working late or on the weekend and can't call right away. I usually do a print screen of the RX and then hand write a note to the MD and fax it right away. I put it in our "fax pending" box so someone else can follow up if necessary (I work part time). My note would say something like, "Patient reports diagnosis of Myasthenia Gravis and is concerned about drug/disease interaction. Please advise."

This wouldn't worry me a great deal if it was during the week when the patient could f/u with the MD the next day. If it happened on a Friday night, I would be hesitant about telling them to stop taking the antibiotic and talk to their doctor on Monday, especially if the prescribing MD was aware of the interaction. That situation is trickier, IMO.

 

[Alby]

There is no question that you did the right thing, even if the patient stated that the physician is aware of the MG diagnosis. Just because the doc know about the diagnosis doesn't mean that he/she is aware of the CI; after all they are human too. No reasonable physician would fault you for your clinical decision (especially since the delay in treatment is <1day). If the infection is so severe that <1day of abx delay is a catastrophe, that pt should have been admitted for IV abx.

Kudos to the patients wife for paying attention!