Cipro (ciprofloxacin hydrochloride) tablet, film coated
Bayer HealthCare Pharmaceuticals Inc.

Bayer HealthCare Pharmaceuticals Inc.
Bayer AG
Bayer AG
Sharp Corporation
Bayer Healthcare Manufacturing Srl
Cipro
ciprofloxacin hydrochloride
CIPROFLOXACIN HYDROCHLORIDE
CIPROFLOXACIN
STARCH, CORN
MICROCRYSTALLINE CELLULOSE
SILICON DIOXIDE
CROSPOVIDONE (120 .MU.M)
MAGNESIUM STEARATE
HYPROMELLOSE, UNSPECIFIED
TITANIUM DIOXIDE
POLYETHYLENE GLYCOL, UNSPECIFIED
ROUND
BAYER;CIP;250
Cipro
ciprofloxacin hydrochloride
CIPROFLOXACIN HYDROCHLORIDE
CIPROFLOXACIN
STARCH, CORN
MICROCRYSTALLINE CELLULOSE
SILICON DIOXIDE
CROSPOVIDONE (120 .MU.M)
MAGNESIUM STEARATE
HYPROMELLOSE, UNSPECIFIED
TITANIUM DIOXIDE
POLYETHYLENE GLYCOL, UNSPECIFIED
OVAL
CIPRO;500
Cipro
ciprofloxacin
Cipro
ciprofloxacin hydrochloride
CIPROFLOXACIN HYDROCHLORIDE
CIPROFLOXACIN
POVIDONE, UNSPECIFIED
METHACRYLIC ACID - METHYL METHACRYLATE COPOLYMER (1:1)
HYPROMELLOSE, UNSPECIFIED
MAGNESIUM STEARATE
POLYSORBATE 20
diluent
diluent
SUCROSE
WATER
Cipro
ciprofloxacin
Cipro
ciprofloxacin hydrochloride
CIPROFLOXACIN HYDROCHLORIDE
CIPROFLOXACIN
POVIDONE, UNSPECIFIED
METHACRYLIC ACID - METHYL METHACRYLATE COPOLYMER (1:1)
HYPROMELLOSE, UNSPECIFIED
MAGNESIUM STEARATE
POLYSORBATE 20
diluent
diluent
SUCROSE
WATER

WARNING: SERIOUS ADVERSE REACTIONS INCLUDING TENDINITIS, TENDON RUPTURE, PERIPHERAL NEUROPATHY, CENTRAL NERVOUS SYSTEM EFFECTS AND EXACERBATION OF MYASTHENIA GRAVIS

  • Fluoroquinolones, including CIPRO®, have been associated with disabling and potentially irreversible serious adverse reactions that have occurred together [see Warnings and Precautions (5.1)], including:
    • Tendinitis and tendon rupture [see Warnings and Precautions (5.2)].
    • Peripheral neuropathy [see Warnings and Precautions (5.3)].
    • Central nervous system effects [see Warnings and Precautions (5.4)].
  •   Discontinue CIPRO immediately and avoid the use of fluoroquinolones, including CIPRO, in patients who experience any of these serious adverse reactions [see Warnings and Precautions (5.1)].
  • Fluoroquinolones, including CIPRO, may exacerbate muscle weakness in patients with myasthenia gravis. Avoid CIPRO in patients with known history of myasthenia gravis. [see Warnings and Precautions (5.5)].
  • Because fluoroquinolones, including CIPRO, have been associated with serious adverse reactions [see Warnings and Precautions (5.1-5.16)], reserve CIPRO for use in patients who have no alternative treatment options for the following indications:
    • Acute exacerbation of chronic bronchitis [see Indications and Usage (1.10)].
    • Acute uncomplicated cystitis [see Indications and Usage (1.11)].
    • Acute sinusitis [see Indications and Usage (1.12)].

WARNING: SERIOUS ADVERSE REACTIONS INCLUDING TENDINITIS, TENDON RUPTURE, PERIPHERAL NEUROPATHY, CENTRAL NERVOUS SYSTEM EFFECTS AND EXACERBATION OF MYASTHENIA GRAVIS

See full prescribing information for complete boxed warning.

  • Fluoroquinolones, including CIPRO®, have been associated with disabling and potentially irreversible serious adverse reactions that have occurred together (5.1), including:
    • Tendinitis and tendon rupture (5.2)
    • Peripheral neuropathy (5.3)
    • Central nervous system effects (5.4)
  •   Discontinue CIPRO immediately and avoid the use of fluoroquinolones, including CIPRO, in patients who experience any of these serious adverse reactions (5.1)
  • Fluoroquinolones, including CIPRO, may exacerbate muscle weakness in patients with myasthenia gravis. Avoid CIPRO in patients with known history of myasthenia gravis. (5.5)
  • Because fluoroquinolones, including CIPRO, have been associated with serious adverse reactions (5.1-5.16), reserve CIPRO for use in patients who have no alternative treatment options for the following indications:
    • Acute exacerbation of chronic bronchitis (1.10)
    • Acute uncomplicated cystitis (1.11)

Acute sinusitis (1.12)

1 INDICATIONS AND USAGE

CIPRO is a fluoroquinolone antibacterial indicated in adults (18 years of age and older) with the following infections caused by designated, susceptible bacteria and in pediatric patients where indicated:

  • Skin and Skin Structure Infections (1.1)
  • Bone and Joint Infections (1.2)
  • Complicated Intra-Abdominal Infections (1.3)
  • Infectious Diarrhea (1.4)
  • Typhoid Fever (Enteric Fever) (1.5)
  • Uncomplicated Cervical and Urethral Gonorrhea (1.6)
  • Inhalational Anthrax post-exposure in adult and pediatric patients (1.7)
  • Plague in adult and pediatric patients (1.8)
  • Chronic Bacterial Prostatitis (1.9)
  • Lower Respiratory Tract Infections (1.10)
    • Acute Exacerbation of Chronic Bronchitis
  • Urinary Tract Infections (1.11)
    • Urinary Tract Infections (UTI)
    • Acute Uncomplicated Cystitis
    • Complicated UTI and Pyelonephritis in Pediatric Patients
  • Acute Sinusitis (1.12)

Usage

To reduce the development of drug-resistant bacteria and maintain the effectiveness of CIPRO and other antibacterial drugs, CIPRO should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. (1.13)

1.1 Skin and Skin Structure Infections

CIPRO is indicated in adult patients for treatment of skin and skin structure infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Proteus vulgaris, Providencia stuartii, Morganella morganii, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus aureus, methicillin-susceptible Staphylococcus epidermidis, or Streptococcus pyogenes.

1.2 Bone and Joint Infections

CIPRO is indicated in adult patients for treatment of bone and joint infections caused by Enterobacter cloacae, Serratia marcescens, or Pseudomonas aeruginosa.

1.3 Complicated Intra-Abdominal Infections

CIPRO is indicated in adult patients for treatment of complicated intra-abdominal infections (used in combination with metronidazole) caused by Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae, or Bacteroides fragilis.

1.4 Infectious Diarrhea

CIPRO is indicated in adult patients for treatment of infectious diarrhea caused by Escherichia coli (enterotoxigenic isolates), Campylobacter jejuni, Shigella boydii , Shigella dysenteriae, Shigella flexneri or Shigella sonnei when antibacterial therapy is indicated.

Although treatment of infections due to this organism in this organ system demonstrated a clinically significant outcome, efficacy was studied in fewer than 10 patients.

1.5 Typhoid Fever (Enteric Fever)

CIPRO is indicated in adult patients for treatment of typhoid fever (enteric fever) caused by Salmonella typhi. The efficacy of ciprofloxacin in the eradication of the chronic typhoid carrier state has not been demonstrated.

1.6 Uncomplicated Cervical and Urethral Gonorrhea

CIPRO is indicated in adult patients for treatment of uncomplicated cervical and urethral gonorrhea due to Neisseria gonorrhoeae [see Warnings and Precautions (5.17)].

1.7 Inhalational Anthrax (Post-Exposure)

CIPRO is indicated in adults and pediatric patients from birth to 17 years of age for inhalational anthrax (post-exposure) to reduce the incidence or progression of disease following exposure to aerosolized Bacillus anthracis.

Ciprofloxacin serum concentrations achieved in humans served as a surrogate endpoint reasonably likely to predict clinical benefit and provided the initial basis for approval of this indication.1 Supportive clinical information for ciprofloxacin for anthrax post-exposure prophylaxis was obtained during the anthrax bioterror attacks of October 2001 [see Clinical Studies (14.2)].

1.8 Plague

CIPRO is indicated for treatment of plague, including pneumonic and septicemic plague, due to Yersinia pestis (Y. pestis) and prophylaxis for plague in adults and pediatric patients from birth to 17 years of age. Efficacy studies of ciprofloxacin could not be conducted in humans with plague for feasibility reasons. Therefore this indication is based on an efficacy study conducted in animals only [see Clinical Studies (14.3)].

1.9 Chronic Bacterial Prostatitis

CIPRO is indicated in adult patients for treatment of chronic bacterial prostatitis caused by Escherichia coli or Proteus mirabilis.

1.10 Lower Respiratory Tract Infections

CIPRO is indicated in adult patients for treatment of lower respiratory tract infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae, Haemophilus parainfluenzae, or Streptococcus pneumoniae.

CIPRO is not a drug of first choice in the treatment of presumed or confirmed pneumonia secondary to Streptococcus pneumoniae.

CIPRO is indicated for the treatment of acute exacerbations of chronic bronchitis (AECB) caused by Moraxella catarrhalis.

Because fluoroquinolones, including CIPRO, have been associated with serious adverse reactions [see Warnings and Precautions (5.1–5.16)] and for some patients AECB is self-limiting, reserve CIPRO for treatment of AECB in patients who have no alternative treatment options.

1.11 Urinary Tract Infections

Urinary Tract Infections in Adults

CIPRO is indicated in adult patients for treatment of urinary tract infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter koseri, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis.

Acute Uncomplicated Cystitis

CIPRO is indicated in adult female patients for treatment of acute uncomplicated cystitis caused by Escherichia coli or Staphylococcus saprophyticus.

Because fluoroquinolones, including CIPRO, have been associated with serious adverse reactions [see Warnings and Precautions (5.1-5.16)] and for some patients acute uncomplicated cystitis is self-limiting, reserve CIPRO for treatment of acute uncomplicated cystitis in patients who have no alternative treatment options.

Complicated Urinary Tract Infection and Pyelonephritis in Pediatric Patients

CIPRO is indicated in pediatric patients aged one to 17 years of age for treatment of complicated urinary tract infections (cUTI) and pyelonephritis due to Escherichia coli [see Use in Specific Populations (8.4)].

Although effective in clinical trials, CIPRO is not a drug of first choice in the pediatric population due to an increased incidence of adverse reactions compared to controls, including reactions related to joints and/or surrounding tissues. CIPRO, like other fluoroquinolones, is associated with arthropathy and histopathological changes in weight-bearing joints of juvenile animals [see Warnings and Precautions (5.13), Adverse Reactions (6.1), Use in Specific Populations (8.4) and Nonclinical Toxicology (13.2)].

1.12 Acute Sinusitis

CIPRO is indicated in adult patients for treatment of acute sinusitis caused by Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis.

Because fluoroquinolones, including CIPRO, have been associated with serious adverse reactions [see Warnings and Precautions (5.1-5.16)] and for some patients acute sinusitis is self-limiting, reserve CIPRO for treatment of acute sinusitis in patients who have no alternative treatment options.

1.13 Usage

To reduce the development of drug-resistant bacteria and maintain the effectiveness of CIPRO and other antibacterial drugs, CIPRO should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

If anaerobic organisms are suspected of contributing to the infection, appropriate therapy should be administered. Appropriate culture and susceptibility tests should be performed before treatment in order to isolate and identify organisms causing infection and to determine their susceptibility to ciprofloxacin. Therapy with CIPRO may be initiated before results of these tests are known; once results become available appropriate therapy should be continued.

As with other drugs, some isolates of Pseudomonas aeruginosa may develop resistance fairly rapidly during treatment with ciprofloxacin. Culture and susceptibility testing performed periodically during therapy will provide information not only on the therapeutic effect of the antimicrobial agent but also on the possible emergence of bacterial resistance.

2 DOSAGE AND ADMINISTRATION

CIPRO Tablets and Oral Suspension should be administered orally as described in the appropriate Dosage Guidelines tables.

Adult Dosage Guidelines
Infection Dose Frequency Duration

Skin and Skin Structure

500 -750 mg

every 12 hours

7 to 14 days

Bone and Joint

500-750 mg

every 12 hours

4 to 8 weeks

Complicated Intra-Abdominal

500 mg

every 12 hours

7 to 14 days

Infectious Diarrhea

500 mg

every 12 hours

5 to 7 days

Typhoid Fever

500 mg

every 12 hours

10 days

Uncomplicated Gonorrhea

250 mg

single dose

single dose

Inhalational anthrax (post-exposure)

500 mg

every 12 hours

60 days

Plague

500–750 mg

every 12 hours

14 days

Chronic Bacterial Prostatitis

500 mg

every 12 hours

28 days

Lower Respiratory Tract

500 -750 mg

every 12 hours

7 to 14 days

Urinary Tract

250-500 mg

every 12 hours

7 to 14 days

Acute Uncomplicated Cystitis

250 mg

every 12 hours

3 days

Acute Sinusitis

500 mg

every 12 hours

10 days

  • Adults with creatinine clearance 30–50 mL/min 250–500 mg q 12 h (2.3)
  • Adults with creatinine clearance 5–29 mL/min 250–500 mg q 18 h (2.3)
  • Patients on hemodialysis or peritoneal dialysis 250–500 mg q 24 h (after dialysis) (2.3)

Pediatric Oral Dosage Guidelines

Infection

Dose

Frequency

Duration

Complicated UTI and Pyelonephritis

(1 to 17 years of age)

10–20 mg/kg

(maximum 750 mg per dose)

Every 12 hours

10–21 days

Inhalational Anthrax

(Post-Exposure)

15 mg/kg

(maximum
500 mg per dose)

Every 12 hours

60 days

Plague

15 mg/kg
(maximum 500 mg per dose)

Every 8 to 12 hours

14 days

2.1 Dosage in Adults

The determination of dosage and duration for any particular patient must take into consideration the severity and nature of the infection, the susceptibility of the causative microorganism, the integrity of the patient’s host-defense mechanisms, and the status of renal and hepatic function. CIPRO Tablets or CIPRO for Oral Suspension may be administered to adult patients when clinically indicated at the discretion of the physician. Administer CIPRO for Oral Suspension using the co-packaged graduated spoon [see Dosage and Administration (2.7)].

Table 1: Adult Dosage Guidelines
  •   Infection
  •   Dose
  •   Frequency
  •   Usual Durations Generally ciprofloxacin should be continued for at least 2 days after the signs and symptoms of infection have disappeared, except for inhalational anthrax (post-exposure).
  •  Skin and Skin Structure
  •  500–750 mg
  •  every 12 hours
  •  7 to 14 days
  •  Bone and Joint
  •  500–750 mg
  •  every 12 hours
  •  4 to 8 weeks
  •  Complicated Intra–AbdominalUsed in conjunction with metronidazole.
  •  500 mg
  •  every 12 hours
  •  7 to 14 days
  •  Infectious Diarrhea
  •  500 mg
  •  every 12 hours
  •  5 to 7 days
  •  Typhoid Fever
  •  500 mg
  •  every 12 hours
  •  10 days
  •  Uncomplicated Urethral and Cervical Gonococcal Infections
  •  250 mg
  •  single dose
  •  single dose
  •  Inhalational anthrax (post-exposure)Begin drug administration as soon as possible after suspected or confirmed exposure.
  •  500 mg
  •  every 12 hours
  •  60 days
  •  Plague
  •  500–750 mg
  •  every 12 hours
  •  14 days
  •  Chronic Bacterial Prostatitis
  •  500 mg
  •  every 12 hours
  •  28 days
  •  Lower Respiratory Tract Infections
  •  500–750 mg
  •  every 12 hours
  •  7 to 14 days
  •  Urinary Tract Infections
  •  250–500 mg
  •  every 12 hours
  •  7 to 14 days
  •  Acute Uncomplicated Cystitis
  •  250 mg
  •  every 12 hours
  •  3 days
  •  Acute Sinusitis
  •  500 mg
  •  every 12 hours
  •  10 days

Conversion of IV to Oral Dosing in Adults

Patients whose therapy is started with CIPRO IV may be switched to CIPRO Tablets or Oral Suspension when clinically indicated at the discretion of the physician (Table 2) [see Clinical Pharmacology (12.3)].

Table 2: Equivalent AUC Dosing Regimens

CIPRO Oral Dosage

Equivalent CIPRO IV Dosage

250 mg Tablet every 12 hours

200 mg intravenous every 12 hours

500 mg Tablet every 12 hours

400 mg intravenous every 12 hours

750 mg Tablet every 12 hours

400 mg intravenous every 8 hours

2.2 Dosage in Pediatric Patients

Dosing and initial route of therapy (that is, IV or oral) for cUTI or pyelonephritis should be determined by the severity of the infection. CIPRO should be administered as described in Table 3. Administer CIPRO for Oral Suspension using the co-packaged graduated spoon [see Dosage and Administration (2.7)].

Table 3: Pediatric Dosage Guidelines
Infection Dose Frequency Total Duration

Complicated Urinary Tract or Pyelonephritis

(patients from 1 to 17 years of age)

10 mg/kg to 20 mg/kg

(maximum 750 mg per dose; not to be exceeded even in patients weighing more than 51 kg)

Every 12 hours

10–21 days

Inhalational Anthrax (Post-Exposure)2

15 mg/kg

(maximum 500 mg per dose)

Every 12 hours

60 days

Plague2,3

15 mg/kg

(maximum 500 mg per dose)

Every 8 to 12 hours

14 days

2.3 Dosage Modifications in Patients with Renal Impairment

Ciprofloxacin is eliminated primarily by renal excretion; however, the drug is also metabolized and partially cleared through the biliary system of the liver and through the intestine. These alternative pathways of drug elimination appear to compensate for the reduced renal excretion in patients with renal impairment. Nonetheless, some modification of dosage is recommended, particularly for patients with severe renal dysfunction. Dosage guidelines for use in patients with renal impairment are shown in Table 4.

Table 4: Recommended Starting and Maintenance Doses for Adult Patients with Impaired Renal Function

Creatinine Clearance (mL/min)

Dose

> 50

See Usual Dosage.

30–50

250–500 mg every 12 hours

5–29

250–500 mg every 18 hours

Patients on hemodialysis or Peritoneal dialysis

250–500 mg every 24 hours (after dialysis)

When only the serum creatinine concentration is known, the following formulas may be used to estimate creatinine clearance:

Men - Creatinine clearance (mL/min) = Weight (kg) x (140–age)

72 x serum creatinine (mg/dL)

Women - 0.85 x the value calculated for men.

The serum creatinine should represent a steady state of renal function.

In patients with severe infections and severe renal impairment, a unit dose of 750 mg may be administered at the intervals noted above. Patients should be carefully monitored.

Pediatric patients with moderate to severe renal insufficiency were excluded from the clinical trial of cUTI and pyelonephritis. No information is available on dosing adjustments necessary for pediatric patients with moderate to severe renal insufficiency (that is, creatinine clearance of < 50 mL/min/1.73m2).

2.4 Important Administration Instructions

With Multivalent Cations

Administer CIPRO at least 2 hours before or 6 hours after magnesium/aluminum antacids; polymeric phosphate binders (for example, sevelamer, lanthanum carbonate) or sucralfate; Videx® (didanosine) chewable/buffered tablets or pediatric powder for oral solution; other highly buffered drugs; or other products containing calcium, iron or zinc.

With Dairy Products

Concomitant administration of CIPRO with dairy products (like milk or yogurt) or calcium-fortified juices alone should be avoided since decreased absorption is possible; however, CIPRO may be taken with a meal that contains these products.

Hydration of Patients Receiving CIPRO

Assure adequate hydration of patients receiving CIPRO to prevent the formation of highly concentrated urine. Crystalluria has been reported with quinolones.

Instruct the patient of the appropriate CIPRO administration [see Patient Counseling Information (17)].

Missed Doses

If a dose is missed, it should be taken anytime but not later than 6 hours prior to the next scheduled dose. If less than 6 hours remain before the next dose, the missed dose should not be taken and treatment should be continued as prescribed with the next scheduled dose. Double doses should not be taken to compensate for a missed dose.

Splitting CIPRO Tablets

CIPRO Tablets, 250 mg and 500 mg are functionally scored tablets which can be split into one-half at the scored line to provide a 125 mg and 250 mg strength, respectively.

2.5 Directions for Reconstitution of the CIPRO Microcapsules for Oral Suspension

CIPRO Oral Suspension is supplied in 5% (5 g ciprofloxacin in 100 mL) and 10% (10 g ciprofloxacin in 100 mL) strengths. CIPRO oral suspension is composed of two components (microcapsules and diluent) that must be combined prior to dispensing.

Table 5: Appropriate Dosing Volumes of the Reconstituted Oral Suspensions

Dose

5%

(250 mg/5 mL)

10%

(500 mg/5 mL)

250 mg

5 mL

2.5 mL

500 mg

10 mL

5 mL

750 mg

15 mL

7.5 mL

Preparation of the suspension:

Step1

Step 1

The small bottle contains the microcapsules, the large bottle contains the diluent.

Step 2

Step 2

Open both bottles. Child-proof cap: Press down according to instructions on the cap while turning to the left.

Step 3

Step 3

Pour the microcapsules completely into the larger bottle of diluent. Do not add water to the suspension.

Step 4

Step 4
  •  Remove the top layer of the diluent bottle label (to reveal the CIPRO Oral Suspension label). Close the large bottle completely according to the directions on the cap and shake vigorously for about 15 seconds. The suspension is ready for use.

Step 5: Write the expiration date of the re-constituted oral suspension on the bottle label.

Reconstituted product may be stored below 30°C (86°F) for 14 days. Protect from freezing.

No additions should be made to the mixed final ciprofloxacin suspension. CIPRO Oral Suspension should not be administered through feeding or NG (nasogastric) tubes due to its physical characteristics.

Step 1
Step 2
Step 3
Step 4

2.6 Administration Instructions for CIPRO for Oral Suspension After Reconstitution

  • Shake CIPRO Oral Suspension vigorously each time before use for approximately 15 seconds.
  • Administer CIPRO Oral Suspension using the co-packaged graduated teaspoon provided for the patient (see Figure 1)
Figure 1: Co-packaged 5 mL graduated teaspoon
gradated spoon

The Co-packaged graduated teaspoon (5mL) is provided, with markings for 1/2 (2.5 mL) and 1/1 (5 mL)

  • After use, clean the graduated teaspoon under running water with dish detergent and dry thoroughly.
  • Do Not chew the microcapsules in the CIPRO Oral Suspension, instead swallow them whole.
  • Water may be taken afterwards.
  • Reclose the bottle properly after each use according to instructions on the cap.

After treatment has been completed, CIPRO Oral Suspension should not be reused.

gradated spoon

2.7 Dosing of CIPRO for Oral Suspension using the Co-Packaged Spoon in Adults and Pediatric Patients

Table : 5% Cipro for Oral Suspension: 250 mg ciprofloxacin per 5 mL after reconstitution

Infection

Body weight (kg)

Dose by Measuring Spoonful(s) using Co-Packed Spoon*
(teaspoonful (s) (volume (mL))

Dose Strength

(mg)

Complicated Urinary Tract or Pyelonephritis (patients from 1 to 17 years of age)1

and Plague2

9 kg to 12 kg

½ teaspoonful (2.5 mL)

125 mg

13 kg to 18 kg

1 teaspoonful (5 mL)

250 mg

19 kg to 24 kg

1 to 1 ½ teaspoonful(s) (5 mL to 7.5 mL)

250 mg to 375 mg

25 kg to 31 kg

1 ½ to 2 teaspoonfuls (7.5 mL to 10 mL)

375 mg to 500 mg

32 kg to 37 kg

1 ½ to 2 ½ teaspoonfuls (7.5 mL to 12.5 mL)

375 mg to 625 mg

38 kg or more

2 to 3 teaspoonfuls (10 mL to 15 mL)

500 mg to 750 mg

Inhalational Anthrax (Post-Exposure)3

9 kg to 12 kg

½ teaspoonful (2.5 mL)

125 mg

13 kg to 18 kg

1 teaspoonful (5 mL)

250 mg

19 kg to 24 kg

1 to 1 ½ teaspoonful(s) (5 mL to 7.5 mL)

250 mg to 375 mg

25 kg or more

2 teaspoonfuls (10 mL)

500 mg

* A graduated teaspoon (5mL) with markings 1/2 (2.5) mL and 1/1 (5 mL) is provided for the patient.

1Administer every 12 hours for 10-21 days [see Dosage and Administration (2.2)]

2Administer every 8-12 hours for 10-21 days for Pediatric patients [see Dosage and Administration (2.2)]; for adults administer every 12 hours for 14 days [see Dosage and Administration (2.1)]

3Administer every 12 hours for 60 days [see Dosage and Administration (2.1 and 2.2)]

Table 7: 10% Oral Suspension: 500 mg ciprofloxacin per 5 mL after reconstitution (not appropriate for children weighing less than 13 kg)

Infection

Body weight (kg)

Dose by Measuring Spoonful(s) using Co-Packed Spoon* (teaspoonful (s) (volume (mL))

Dose Strength

(mg)

Complicated Urinary Tract or Pyelonephritis (patients from 1 to 17 years of age)1

and Plague2

13 kg to 24 kg

½ teaspoonful (2.5 mL)

250 mg

25 kg

½ to 1 teaspoonful (2.5 mL to 5 mL)

250 mg to 500 mg

26 kg to 37 kg

1 teaspoonful (5 mL)

500 mg

38 kg or more

1 to 1½ teaspoonful(s) (5 mL to 7.5 mL)

500 mg to maximum dose of 750 mg

Inhalational Anthrax (Post-Exposure)3

13 kg to 24 kg

½ teaspoonful (2.5 mL)

250 mg

25 kg or more

1 teaspoonful (5 mL)

500 mg

* A graduated teaspoon (5mL) with markings 1/2 (2.5) mL and 1/1 (5 mL) is provided for the patient.

1Administer every 12 hours for 10-21 days [see Dosage and Administration (2.2)]

2Administer every 8-12 hours for 10-21 days for Pediatric patients [see Dosage and Administration (2.2)]; for adults administer every 12 hours for 14 days [see Dosage and Administration (2.1)]

3Administer every 12 hours for 60 days [see Dosage and Administration (2.1 and 2.2)]

3 DOSAGE FORMS AND STRENGTHS

  • Tablets: 250 mg, functionally scored and 500 mg (3)
  • Oral Suspension: 5% (250 mg/5 mL), 10% (500 mg/5 mL) (3)

3.1 Tablets

  • 250 mg slightly yellowish, film-coated, round, functionally scored, imprinted with “BAYER” on one side and “CIP 250” on the other
  • 500 mg, slightly yellowish, film-coated, capsule shaped, functionally scored, imprinted with “BAYER” on one side and “CIP 500” on the other

3.2 Oral Suspension

  • 5% Oral Suspension: 250 mg ciprofloxacin per 5 mL after reconstitution
  • 10% Oral Suspension: 500 mg ciprofloxacin per 5 mL after reconstitution

4 CONTRAINDICATIONS

  • Known hypersensitivity to CIPRO or other quinolones (4.1, 5.6, 5.7)
  • Concomitant administration with tizanidine (4.2)

4.1 Hypersensitivity

CIPRO is contraindicated in persons with a history of hypersensitivity to ciprofloxacin, any member of the quinolone class of antibacterials, or any of the product components [see Warnings and Precautions (5.7)].

4.2 Tizanidine

Concomitant administration with tizanidine is contraindicated [see Drug Interactions (7)].

5 WARNINGS AND PRECAUTIONS

  • Hypersensitivity and other serious reactions: Serious and sometimes fatal reactions (for example, anaphylactic reactions) may occur after the first or subsequent doses of CIPRO. Discontinue CIPRO at the first sign of skin rash, jaundice or any sign of hypersensitivity. (4.1, 5.6, 5.7)
  • Hepatotoxicity: Discontinue immediately if signs and symptoms of hepatitis occur. (5.8)
  • Clostridioides difficile-associated diarrhea: Evaluate if colitis occurs. (5.11)
  • QT Prolongation: Prolongation of the QT interval and isolated cases of torsade de pointes have been reported. Avoid use in patients with known prolongation, those with hypokalemia, and with other drugs that prolong the QT interval. (5.12, 7, 8.5)

5.1 Disabling and Potentially Irreversible Serious Adverse Reactions Including Tendinitis and Tendon Rupture, Peripheral Neuropathy, and Central Nervous System Effects

Fluoroquinolones, including CIPRO, have been associated with disabling and potentially irreversible serious adverse reactions from different body systems that can occur together in the same patient. Commonly seen adverse reactions include tendinitis, tendon rupture, arthralgia, myalgia, peripheral neuropathy, and central nervous system effects (hallucinations, anxiety, depression, insomnia, severe headaches, and confusion). These reactions can occur within hours to weeks after starting CIPRO. Patients of any age or without pre-existing risk factors have experienced these adverse reactions [see Warnings and Precautions (5.2, 5.3, 5.4)].

Discontinue CIPRO immediately at the first signs or symptoms of any serious adverse reaction. In addition, avoid the use of fluoroquinolones, including CIPRO, in patients who have experienced any of these serious adverse reactions associated with fluoroquinolones.

5.2 Tendinitis and Tendon Rupture

Fluoroquinolones, including CIPRO, have been associated with an increased risk of tendinitis and tendon rupture in all ages [see Warnings and Precautions (5.1) and Adverse Reactions (6.2)]. This adverse reaction most frequently involves the Achilles tendon, and has also been reported with the rotator cuff (the shoulder), the hand, the biceps, the thumb, and other tendons. Tendinitis or tendon rupture can occur, within hours or days of starting CIPRO, or as long as several months after completion of fluoroquinolone therapy.. Tendinitis and tendon rupture can occur bilaterally.

The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is increased in patients over 60 years of age, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants. Other factors that may independently increase the risk of tendon rupture include strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis. Tendinitis and tendon rupture have also occurred in patients taking fluoroquinolones who do not have the above risk factors. Discontinue CIPRO immediately if the patient experiences pain, swelling, inflammation or rupture of a tendon. Avoid fluoroquinolones, including CIPRO, in patients who have a history of tendon disorders or have experienced tendinitis or tendon rupture [see Adverse Reactions (6.2)].

5.3 Peripheral Neuropathy

Fluoroquinolones, including CIPRO, have been associated with an increased risk of peripheral neuropathy. Cases of sensory or sensorimotor axonal polyneuropathy affecting small and/or large axons resulting in paresthesias, hypoesthesias, dysesthesias and weakness have been reported in patients receiving fluoroquinolones, including CIPRO. Symptoms may occur soon after initiation of CIPRO and may be irreversible in some patients [see Warnings and Precautions (5.1) and Adverse Reactions (6.1, 6.2)].

Discontinue CIPRO immediately if the patient experiences symptoms of peripheral neuropathy including pain, burning, tingling, numbness, and/or weakness, or other alterations in sensations including light touch, pain, temperature, position sense and vibratory sensation, and/or motor strength in order to minimize the development of an irreversible condition. Avoid fluoroquinolones, including CIPRO, in patients who have previously experienced peripheral neuropathy [see Adverse Reactions (6.1, 6.2)].

5.4 Central Nervous System Effects

Psychiatric Adverse Reactions

Fluoroquinolones, including CIPRO, have been associated with an increased risk of psychiatric adverse reactions, including: toxic psychosis, psychotic reactions progressing to suicidal ideations/thoughts, hallucinations, or paranoia; depression, or self-injurious behavior such as attempted or completed suicide; anxiety, agitation, or nervousness; confusion, delirium, disorientation, or disturbances in attention; insomnia or nightmares; memory impairment. These reactions may occur following the first dose. Advise patients receiving CIPRO to inform their healthcare provider immediately if these reactions occur, discontinue the drug, and institute appropriate care.

Central Nervous System Adverse Reactions

Fluoroquinolones, including CIPRO, have been associated with an increased risk of seizures (convulsions), increased intracranial pressure (pscudotumor cerebri), dizziness, and tremors. CIPRO, like other fluoroquinolones, is known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. As with all fluoroquinolones, use CIPRO with caution in epileptic patients and patients with known or suspected CNS disorders that may predispose to seizures or lower the seizure threshold (for example, severe cerebral arteriosclerosis, previous history of convulsion, reduced cerebral blood flow, altered brain structure, or stroke), or in the presence of other risk factors that may predispose to seizures or lower the seizure threshold (for example, certain drug therapy, renal dysfunction). If seizures occur, discontinue CIPRO and institute appropriate care [see Adverse Reactions (6.1) and Drug Interactions (7)].

5.5 Exacerbation of Myasthenia Gravis

Fluoroquinolones, including CIPRO, have neuromuscular blocking activity and may exacerbate muscle weakness in patients with myasthenia gravis. Postmarketing serious adverse reactions, including deaths and requirement for ventilatory support, have been associated with fluoroquinolone use in patients with myasthenia gravis. Avoid CIPRO in patients with known history of myasthenia gravis [see Adverse Reactions (6.2)].

5.6 Other Serious and Sometimes Fatal Adverse Reactions

Other serious and sometimes fatal adverse reactions, some due to hypersensitivity, and some due to uncertain etiology, have been reported in patients receiving therapy with quinolones, including CIPRO. These events may be severe and generally occur following the administration of multiple doses. Clinical manifestations may include one or more of the following:

  • Fever, rash, or severe dermatologic reactions (for example, toxic epidermal necrolysis, Stevens-Johnson syndrome);
  • Vasculitis; arthralgia; myalgia; serum sickness;
  • Allergic pneumonitis;
  • Interstitial nephritis; acute renal insufficiency or failure;
  • Hepatitis; jaundice; acute hepatic necrosis or failure;
  • Anemia, including hemolytic and aplastic; thrombocytopenia, including thrombotic thrombocytopenic purpura; leukopenia; agranulocytosis; pancytopenia; and/or other hematologic abnormalities.

Discontinue CIPRO immediately at the first appearance of a skin rash, jaundice, or any other sign of hypersensitivity and supportive measures instituted [see Adverse Reactions (6.1, 6.2)].

5.7 Hypersensitivity Reactions

Serious and occasionally fatal hypersensitivity (anaphylactic) reactions, some following the first dose, have been reported in patients receiving fluoroquinolone therapy, including CIPRO. Some reactions were accompanied by cardiovascular collapse, loss of consciousness, tingling, pharyngeal or facial edema, dyspnea, urticaria, and itching. Only a few patients had a history of hypersensitivity reactions. Serious anaphylactic reactions require immediate emergency treatment with epinephrine and other resuscitation measures, including oxygen, intravenous fluids, intravenous antihistamines, corticosteroids, pressor amines, and airway management, including intubation, as indicated [see Adverse Reactions (6.1)].

5.8 Hepatotoxicity

Cases of severe hepatotoxicity, including hepatic necrosis, life-threatening hepatic failure, and fatal events, have been reported with CIPRO. Acute liver injury is rapid in onset (range 1–39 days), and is often associated with hypersensitivity. The pattern of injury can be hepatocellular, cholestatic, or mixed. Most patients with fatal outcomes were older than 55 years old. In the event of any signs and symptoms of hepatitis (such as anorexia, jaundice, dark urine, pruritus, or tender abdomen), discontinue treatment immediately.

There can be a temporary increase in transaminases, alkaline phosphatase, or cholestatic jaundice, especially in patients with previous liver damage, who are treated with CIPRO [see Adverse Reactions (6.2, 6.3)].

5.9 Risk of Aortic Aneurysm and Dissection

Epidemiologic studies report an increased rate of aortic aneurysm and dissection within two months following use of fluoroquinolones, particularly in elderly patients. The cause for the increased risk has not been identified. In patients with a known aortic aneurysm or patients who are at greater risk for aortic aneurysms, reserve CIPRO for use only when there are no alternative antibacterial treatments available.

5.10 Serious Adverse Reactions with Concomitant Theophylline

Serious and fatal reactions have been reported in patients receiving concurrent administration of CIPRO and theophylline. These reactions have included cardiac arrest, seizure, status epilepticus, and respiratory failure. Instances of nausea, vomiting, tremor, irritability, or palpitation have also occurred.

Although similar serious adverse reactions have been reported in patients receiving theophylline alone, the possibility that these reactions may be potentiated by CIPRO cannot be eliminated. If concomitant use cannot be avoided, monitor serum levels of theophylline and adjust dosage as appropriate [see Drug Interactions (7)].

5.11 Clostridioides difficile-Associated Diarrhea

Clostridioides difficile (C. difficile)-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including CIPRO, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.

C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing isolates of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.

If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and institute surgical evaluation as clinically indicated [see Adverse Reactions (6.1)].

5.12 Prolongation of the QT Interval

Some fluoroquinolones, including CIPRO, have been associated with prolongation of the QT interval on the electrocardiogram and cases of arrhythmia. Cases of torsade de pointes have been reported during postmarketing surveillance in patients receiving fluoroquinolones, including CIPRO.

Avoid CIPRO in patients with known prolongation of the QT interval, risk factors for QT prolongation or torsade de pointes (for example, congenital long QT syndrome, uncorrected electrolyte imbalance, such as hypokalemia or hypomagnesemia and cardiac disease, such as heart failure, myocardial infarction, or bradycardia), and patients receiving Class IA antiarrhythmic agents (quinidine, procainamide), or Class III antiarrhythmic agents (amiodarone, sotalol), tricyclic antidepressants, macrolides, and antipsychotics. Elderly patients may also be more susceptible to drug-associated effects on the QT interval [see Adverse Reactions (6.2), Use in Specific Populations (8.5)].

5.13 Musculoskeletal Disorders in Pediatric Patients and Arthropathic Effects in Animals

CIPRO is indicated in pediatric patients (less than 18 years of age) only for cUTI, prevention of inhalational anthrax (post exposure), and plague [see Indications and Usage (1.7, 1.8, 1.11)]. An increased incidence of adverse reactions compared to controls, including reactions related to joints and/or surrounding tissues, has been observed [see Adverse Reactions (6.1)].

In pre-clinical studies, oral administration of CIPRO caused lameness in immature dogs. Histopathological examination of the weight-bearing joints of these dogs revealed permanent lesions of the cartilage. Related quinolone-class drugs also produce erosions of cartilage of weight-bearing joints and other signs of arthropathy in immature animals of various species [see Use in Specific Populations (8.4) and Nonclinical Toxicology (13.2)].

5.14 Photosensitivity/Phototoxicity

Moderate to severe photosensitivity/phototoxicity reactions, the latter of which may manifest as exaggerated sunburn reactions (for example, burning, erythema, exudation, vesicles, blistering, edema) involving areas exposed to light (typically the face, “V” area of the neck, extensor surfaces of the forearms, dorsa of the hands), can be associated with the use of quinolones including CIPRO after sun or UV light exposure. Therefore, avoid excessive exposure to these sources of light. Discontinue CIPRO if phototoxicity occurs [see Adverse Reactions (6.1)].

5.15 Development of Drug Resistant Bacteria

Prescribing CIPRO Tablets and CIPRO Oral Suspension in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

5.16 Potential Risks with Concomitant Use of Drugs Metabolized by Cytochrome P450 1A2 Enzymes

CIPRO is an inhibitor of the hepatic CYP1A2 enzyme pathway. Co-administration of CIPRO and other drugs primarily metabolized by CYP1A2 (for example, theophylline, methylxanthines, caffeine, tizanidine, ropinirole, clozapine, olanzapine and zolpidem), results in increased plasma concentrations of the co-administered drug and could lead to clinically significant pharmacodynamic adverse reactions of the co-administered drug [see Drug Interactions (7) and Clinical Pharmacology (12.3)].

5.17 Interference with Timely Diagnosis of Syphilis

CIPRO has not been shown to be effective in the treatment of syphilis. Antimicrobial agents used in high dose for short periods of time to treat gonorrhea may mask or delay the symptoms of incubating syphilis. Perform a serologic test for syphilis in all patients with gonorrhea at the time of diagnosis. Perform follow-up serologic test for syphilis three months after CIPRO treatment.

5.18 Crystalluria

Crystals of ciprofloxacin have been observed rarely in the urine of human subjects but more frequently in the urine of laboratory animals, which is usually alkaline [see Nonclinical Toxicology (13.2)]. Crystalluria related to CIPRO has been reported only rarely in humans because human urine is usually acidic. Avoid alkalinity of the urine in patients receiving CIPRO. Hydrate patients well to prevent the formation of highly concentrated urine [see Dosage and Administration (2.4)].

5.19 Blood Glucose Disturbances

Fluoroquinolones, including CIPRO, have been associated with disturbances of blood glucose, including symptomatic hyperglycemia and hypoglycemia, usually in diabetic patients receiving concomitant treatment with an oral hypoglycemic agent (for example, glyburide) or with insulin. In these patients, careful monitoring of blood glucose is recommended. Severe cases of hypoglycemia resulting in coma or death have been reported. If a hypoglycemic reaction occurs in a patient being treated with CIPRO, discontinue CIPRO and initiate appropriate therapy immediately [see Adverse Reactions (6.1), Drug Interactions (7)].

6 ADVERSE REACTIONS

The following serious and otherwise important adverse drug reactions are discussed in greater detail in other sections of labeling:

  • Disabling and Potentially Irreversible Serious Adverse Reactions [see Warnings and Precautions (5.1)]
  • Tendinitis and Tendon Rupture [see Warnings and Precautions (5.2)]
  • Peripheral Neuropathy [see Warnings and Precautions (5.3)]
  • Central Nervous System Effects [see Warnings and Precautions (5.4)] Exacerbation of Myasthenia Gravis [see Warnings and Precautions (5.5)]
  • Other Serious and Sometimes Fatal Adverse Reactions [see Warnings and Precautions (5.6)]
  • Hypersensitivity Reactions [see Warnings and Precautions (5.7)]
  • Hepatotoxicity [see Warnings and Precautions (5.8)]
  • Risk of Aortic Aneurysm and Dissection [see Warnings and Precautions (5.9)]
  • Serious Adverse Reactions with Concomitant Theophylline [see Warnings and Precautions (5.10)]
  • Clostridioides difficile-Associated Diarrhea [see Warnings and Precautions (5.11)]
  • Prolongation of the QT Interval [see Warnings and Precautions (5.12)]
  • Musculoskeletal Disorders in Pediatric Patients [see Warnings and Precautions (5.13)]
  • Photosensitivity/Phototoxicity [see Warnings and Precautions (5.14)]
  • Development of Drug Resistant Bacteria [see Warnings and Precautions (5.15)]

The most common adverse reactions ≥1% were nausea, diarrhea, liver function tests abnormal, vomiting, and rash. (6)

To report SUSPECTED ADVERSE REACTIONS, contact Bayer HealthCare Pharmaceuticals Inc. at 1-888-842-2937 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adult Patients

During clinical investigations with oral and parenteral CIPRO, 49,038 patients received courses of the drug.

The most frequently reported adverse reactions, from clinical trials of all formulations, all dosages, all drug-therapy durations, and for all indications of ciprofloxacin therapy were nausea (2.5%), diarrhea (1.6%), liver function tests abnormal (1.3%), vomiting (1%), and rash (1%).

Table 8: Medically Important Adverse Reactions That Occurred In less than 1% of Ciprofloxacin Patients
System Organ Class Adverse Reactions

Body as a Whole

Headache

Abdominal Pain/Discomfort

Pain

Cardiovascular

Syncope

Angina Pectoris

Myocardial Infarction

Cardiopulmonary Arrest

Tachycardia

Hypotension

Central Nervous System

Restlessness

Dizziness

Insomnia

Nightmares

Hallucinations

Paranoia

Psychosis (toxic)

Manic Reaction

Irritability

Tremor

Ataxia

Seizures (including Status Epilepticus)

Malaise

Anorexia

Phobia

Depersonalization

Depression (potentially culminating in self-injurious behavior

(such as suicidal ideations/thoughts and attempted or completed suicide)

Paresthesia

Abnormal Gait

Migraine

Gastrointestinal

Intestinal Perforation

Gastrointestinal Bleeding

Cholestatic Jaundice

Hepatitis

Pancreatitis

Hemic/Lymphatic

Petechia

Metabolic/Nutritional

Hyperglycemia

Hypoglycemia

Musculoskeletal

Arthralgia

Joint Stiffness

Muscle Weakness

Renal/Urogenital

Interstitial Nephritis

Renal Failure

Respiratory

Dyspnea

Laryngeal Edema

Hemoptysis

Bronchospasm

Skin/Hypersensitivity

Anaphylactic Reactions including life-threatening anaphylactic shock

Erythema Multiforme/Stevens-Johnson Syndrome

Exfoliative Dermatitis

Toxic Epidermal Necrolysis

Pruritus

Urticaria

Photosensitivity/Phototoxicity reaction

Flushing

Fever

Angioedema

Erythema Nodosum

Sweating

Special Senses

Blurred Vision

Disturbed Vision (chromatopsia and photopsia)

Decreased Visual Acuity

Diplopia

Tinnitus

Hearing Loss

Bad Taste

In randomized, double-blind controlled clinical trials comparing CIPRO tablets [500 mg two times daily (BID)] to cefuroxime axetil (250 mg–500 mg BID) and to clarithromycin (500 mg BID) in patients with respiratory tract infections, CIPRO demonstrated a CNS adverse reaction profile comparable to the control drugs.

Pediatric Patients

Short (6 weeks) and long term (1 year) musculoskeletal and neurological safety of oral/intravenous ciprofloxacin, was compared to a cephalosporin for treatment of cUTI or pyelonephritis in pediatric patients 1 to 17 years of age (mean age of 6 ± 4 years) in an international multicenter trial. The duration of therapy was 10 to 21 days (mean duration of treatment was 11 days with a range of 1 to 88 days). A total of 335 ciprofloxacin- and 349 comparator-treated patients were enrolled.

An Independent Pediatric Safety Committee (IPSC) reviewed all cases of musculoskeletal adverse reactions including abnormal gait or abnormal joint exam (baseline or treatment-emergent). Within 6 weeks of treatment initiation, the rates of musculoskeletal adverse reactions were 9.3% (31/335) in the ciprofloxacin-treated group versus 6% (21/349) in comparator-treated patients. All musculoskeletal adverse reactions occurring by 6 weeks resolved (clinical resolution of signs and symptoms), usually within 30 days of end of treatment. Radiological evaluations were not routinely used to confirm resolution of the adverse reactions. Ciprofloxacin-treated patients were more likely to report more than one adverse reaction and on more than one occasion compared to control patients. The rate of musculoskeletal adverse reactions was consistently higher in the ciprofloxacin group compared to the control group across all age subgroups. At the end of 1 year, the rate of these adverse reactions reported at any time during that period was 13.7% (46/335) in the ciprofloxacin-treated group versus 9.5% (33/349) in the comparator-treated patients (Table 9).

Table 9: Musculoskeletal Adverse ReactionsIncluded: arthralgia, abnormal gait, abnormal joint exam, joint sprains, leg pain, back pain, arthrosis, bone pain, pain, myalgia, arm pain, and decreased range of motion in a joint (knee, elbow, ankle, hip, wrist, and shoulder) as Assessed by the IPSC
  •   CIPRO
  •   Comparator
  •  All Patients (within 6 weeks)
  •  31/335 (9.3%)
  •  21/349 (6%)
  •  95% Confidence IntervalThe study was designed to demonstrate that the arthropathy rate for the ciprofloxacin group did not exceed that of the control group by more than + 6%. At both the 6 week and 1 year evaluations, the 95% confidence interval indicated that it could not be concluded that the ciprofloxacin group had findings comparable to the control group.
  •  (-0.8%, +7.2%)
  •  Age Group
  •  12 months < 24 months
  •  1/36 (2.8%)
  •  0/41
  •  2 years < 6 years
  •  5/124 (4%)
  •  3/118 (2.5%)
  •  6 years < 12 years
  •  18/143 (12.6%)
  •  12/153 (7.8%)
  •  12 years to 17 years
  •  7/32 (21.9%)
  •  6/37 (16.2 %)
  •  All Patients (within 1 year)
  •  46/335 (13.7%)
  •  33/349 (9.5%)
  •  95% Confidence Interval
  •  (-0.6%, + 9.1%)

The incidence rates of neurological adverse reactions within 6 weeks of treatment initiation were 3% (9/335) in the CIPRO group versus 2% (7/349) in the comparator group and included dizziness, nervousness, insomnia, and somnolence.

In this trial, the overall incidence rates of adverse reactions within 6 weeks of treatment initiation were 41% (138/335) in the ciprofloxacin group versus 31% (109/349) in the comparator group. The most frequent adverse reactions were gastrointestinal: 15% (50/335) of ciprofloxacin patients compared to 9% (31/349) of comparator patients. Serious adverse reactions were seen in 7.5% (25/335) of ciprofloxacin-treated patients compared to 5.7% (20/349) of control patients. Discontinuation of drug due to an adverse reaction was observed in 3% (10/335) of ciprofloxacin-treated patients versus 1.4% (5/349) of comparator patients. Other adverse reactions that occurred in at least 1% of ciprofloxacin patients were diarrhea 4.8%, vomiting 4.8%, abdominal pain 3.3%, dyspepsia 2.7%, nausea 2.7%, fever 2.1%, asthma 1.8% and rash 1.8%.

Short-term safety data for ciprofloxacin was also collected in a randomized, double-blind clinical trial for the treatment of acute pulmonary exacerbations in cystic fibrosis patients (ages 5–17 years). Sixty seven patients received CIPRO IV 10 mg/kg/dose every 8 hours for one week followed by CIPRO tablets 20 mg/kg/dose every 12 hours to complete 10–21 days treatment and 62 patients received the combination of ceftazidime intravenous 50 mg/kg/dose every 8 hours and tobramycin intravenous 3 mg/kg/dose every 8 hours for a total of 10–21 days. Periodic musculoskeletal assessments were conducted by treatment-blinded examiners. Patients were followed for an average of 23 days after completing treatment (range 0–93 days). Musculoskeletal adverse reactions were reported in 22% of the patients in the ciprofloxacin group and 21% in the comparison group. Decreased range of motion was reported in 12% of the subjects in the ciprofloxacin group and 16% in the comparison group. Arthralgia was reported in 10% of the patients in the ciprofloxacin group and 11% in the comparison group. Other adverse reactions were similar in nature and frequency between treatment arms. The efficacy of CIPRO for the treatment of acute pulmonary exacerbations in pediatric cystic fibrosis patients has not been established.

In addition to the adverse reactions reported in pediatric patients in clinical trials, it should be expected that adverse reactions reported in adults during clinical trials or postmarketing experience may also occur in pediatric patients.

6.2 Postmarketing Experience

The following adverse reactions have been reported from worldwide marketing experience with fluoroquinolones, including CIPRO. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure (Table 10).

Table 10: Postmarketing Reports of Adverse Drug Reactions

System Organ Class

Adverse Reactions

Cardiovascular

QT prolongation

Torsade de Pointes

Vasculitis and ventricular arrhythmia

Central Nervous System

Hypertonia

Myasthenia

Exacerbation of myasthenia gravis

Peripheral neuropathy

Polyneuropathy

Twitching

Eye Disorders

Nystagmus

Gastrointestinal

Pseudomembranous colitis

Hemic/Lymphatic

Pancytopenia (life threatening or fatal outcome)

Methemoglobinemia

Hepatobiliary

Hepatic failure (including fatal cases)

Infections and Infestations

Candidiasis (oral, gastrointestinal, vaginal)

Investigations

Prothrombin time prolongation or decrease

Cholesterol elevation (serum)

Potassium elevation (serum)

Musculoskeletal

Myalgia

Myoclonus

Tendinitis

Tendon rupture

Psychiatric Disorders

Agitation

Confusion

Delirium

Skin/Hypersensitivity

Acute generalize exanthematous pustulosis (AGEP)

Fixed eruption

Serum sickness-like reaction

Special Senses

Anosmia

Hyperesthesia

Hypesthesia

Taste loss

6.3 Adverse Laboratory Changes

Changes in laboratory parameters while on CIPRO are listed below:

  •  Hepatic –Elevations of ALT (SGPT), AST (SGOT), alkaline phosphatase, LDH, serum bilirubin.

Hematologic–Eosinophilia, leukopenia, decreased blood platelets, elevated blood platelets, pancytopenia.

Renal–Elevations of serum creatinine, BUN, crystalluria, cylindruria, and hematuria have been reported.

Other changes occurring were: elevation of serum gammaglutamyl transferase, elevation of serum amylase, reduction in blood glucose, elevated uric acid, decrease in hemoglobin, anemia, bleeding diathesis, increase in blood monocytes, and leukocytosis.

7 DRUG INTERACTIONS

Ciprofloxacin is an inhibitor of human cytochrome P450 1A2 (CYP1A2) mediated metabolism. Co-administration of CIPRO with other drugs primarily metabolized by CYP1A2 results in increased plasma concentrations of these drugs and could lead to clinically significant adverse events of the co-administered drug.

Table 11: Drugs That are Affected by and Affecting CIPRO

Drugs That are Affected by CIPRO

Drug(s)

Recommendation

Comments

Tizanidine

  •  Contraindicated

Concomitant administration of tizanidine and CIPRO is contraindicated due to the potentiation of hypotensive and sedative effects of tizanidine [see Contraindications (4.2)]

Theophylline

Avoid Use

(Plasma Exposure Likely to be Increased and Prolonged)

Concurrent administration of CIPRO with theophylline may result in increased risk of a patient developing central nervous system (CNS) or other adverse reactions. If concomitant use cannot be avoided, monitor serum levels of theophylline and adjust dosage as appropriate [see Warnings and Precautions (5.10)].

Drugs Known to Prolong QT Interval

  •  Avoid Use

CIPRO may further prolong the QT interval in patients receiving drugs known to prolong the QT interval (for example, class IA or III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics) [see Warnings and Precautions (5.12) and Use in Specific Populations (8.5)].

Oral antidiabetic drugs

Use with caution

Glucose-lowering effect potentiated

Hypoglycemia sometimes severe has been reported when CIPRO and oral antidiabetic agents, mainly sulfonylureas (for example, glyburide, glimepiride), were co-administered, presumably by intensifying the action of the oral antidiabetic agent. Fatalities have been reported. Monitor blood glucose when CIPRO is co-administered with oral antidiabetic drugs [see Adverse Reactions (6.1)].

Phenytoin

Use with caution

Altered serum levels of phenytoin (increased and decreased)

To avoid the loss of seizure control associated with decreased phenytoin levels and to prevent phenytoin overdose-related adverse reactions upon CIPRO discontinuation in patients receiving both agents, monitor phenytoin therapy, including phenytoin serum concentration during and shortly after co-administration of CIPRO with phenytoin.

Cyclosporine

Use with caution

(transient elevations in serum creatinine)

Monitor renal function (in particular serum creatinine) when CIPRO is co-administered with cyclosporine.

Anti-coagulant drugs

Use with caution

(Increase in anticoagulant effect)

The risk may vary with the underlying infection, age and general status of the patient so that the contribution of CIPRO to the increase in INR (international normalized ratio) is difficult to assess. Monitor prothrombin time and INR frequently during and shortly after co-administration of CIPRO with an oral anti-coagulant (for example, warfarin).

Methotrexate

Use with caution

Inhibition of methotrexate renal tubular transport potentially leading to increased methotrexate plasma levels

Potential increase in the risk of methotrexate associated toxic reactions. Therefore, carefully monitor patients under methotrexate therapy when concomitant CIPRO therapy is indicated.

Ropinirole

  •  Use with caution

Monitoring for ropinirole-related adverse reactions and appropriate dose adjustment of ropinirole is recommended during and shortly after co-administration with CIPRO [see Warnings and Precautions (5.16)].

Clozapine

  •  Use with caution

Careful monitoring of clozapine associated adverse reactions and appropriate adjustment of clozapine dosage during and shortly after co-administration with CIPRO are advised.

NSAIDs

  •  Use with caution

Non-steroidal anti-inflammatory drugs (but not acetyl salicylic acid) in combination of very high doses of quinolones have been shown to provoke convulsions in pre-clinical studies and in postmarketing.

Sildenafil

Use with caution

Two-fold increase in exposure

Monitor for sildenafil toxicity [see Clinical Pharmacology (12.3 )].

Duloxetine

Avoid Use

Five-fold increase in duloxetine exposure

If unavoidable, monitor for duloxetine toxicity

Caffeine/Xanthine Derivatives

Use with caution

Reduced clearance resulting in elevated levels and prolongation of serum half-life

CIPRO inhibits the formation of paraxanthine after caffeine administration (or pentoxifylline containing products). Monitor for xanthine toxicity and adjust dose as necessary.

Zolpidem

Avoid Use

Co-administration with ciprofloxacin may increase blood levels of zolpidem, concurrent use is not recommended

Drug(s) Affecting Pharmacokinetics of CIPRO

Antacids, Sucralfate, Multivitamins and Other Products Containing Multivalent Cations (magnesium/aluminum antacids; polymeric phosphate binders (for example, sevelamer, lanthanum carbonate); sucralfate; Videx® (didanosine) chewable/buffered tablets or pediatric powder; other highly buffered drugs; or products containing calcium, iron, or zinc and dairy products)

CIPRO should be taken at least two hours before or six hours after Multivalent cation-containing products administration [see Dosage and Administration (2.4)].

Decrease CIPRO absorption, resulting in lower serum and urine levels

Probenecid

Use with caution

(interferes with renal tubular secretion of CIPRO and increases CIPRO serum levels)

Potentiation of CIPRO toxicity may occur.

Interacting Drug Interaction

Theophylline

Serious and fatal reactions. Avoid concomitant use. Monitor serum level (7)

Warfarin

Anticoagulant effect enhanced. Monitor prothrombin time, INR, and bleeding (7)

Antidiabetic agents

Hypoglycemia including fatal outcomes have been reported. Monitor blood glucose (7)

Phenytoin

Monitor phenytoin level (7)

Methotrexate

Monitor for methotrexate toxicity (7)

Cyclosporine

May increase serum creatinine. Monitor serum creatinine (7)

Multivalent cation-containing products including antacids, metal cations or didanosine

Decreased CIPRO absorption. Take CIPRO 2 hours before or 6 hours after administration of multivalent cation containing drugs (7)

8 USE IN SPECIFIC POPULATIONS

  •   Lactation: Breastfeeding is not recommended during treatment, but a lactating
    woman may pump and discard breastmilk during treatment and an additional 2 days after the last dose. In patients treated for inhalational anthrax (post exposure), consider the risks and benefits of continuing breastfeeding. ( 8.2 )
  •   See full prescribing information for use in pediatric and geriatric patients (8.4, 8.5)

8.1 Pregnancy

Risk Summary

Prolonged experience with ciprofloxacin in pregnant women over several decades, based on available published information from case reports, case control studies and observational studies on ciprofloxacin administered during pregnancy, have not identified any drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes (see Data). Oral administration of ciprofloxacin during organogenesis at doses up to 100 mg/kg to pregnant mice and rats, and up to 30 mg/kg to pregnant rabbits did not cause fetal malformations (see Data). These doses were up to 0.3, 0.6, and 0.4 times the maximum recommended clinical oral dose in mice, rats, and rabbits, respectively, based on body surface area. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Data

Human Data

While available studies cannot definitively establish the absence of risk, published data from prospective observational studies over several decades have not established an association with ciprofloxacin use during pregnancy and major birth defects, miscarriage, or adverse maternal or fetal outcomes. Available studies have methodological limitations including small sample size and some of them are not specific for ciprofloxacin. A controlled prospective observational study followed 200 women exposed to fluoroquinolones (52.5% exposed to ciprofloxacin and 68% first trimester exposures) during gestation. In utero exposure to fluoroquinolones during embryogenesis was not associated with increased risk of major malformations. The reported rates of major congenital malformations were 2.2% for the fluoroquinolone group and 2.6% for the control group (background incidence of major malformations is 1–5%). Rates of spontaneous abortions, prematurity and low birth weight did not differ between the groups and there were no clinically significant musculoskeletal dysfunctions up to one year of age in the ciprofloxacin exposed children.

Another prospective follow-up study reported on 549 pregnancies with fluoroquinolone exposure (93% first trimester exposures). There were 70 ciprofloxacin exposures, all within the first trimester. The malformation rates among live-born babies exposed to ciprofloxacin and to fluoroquinolones overall were both within background incidence ranges. No specific patterns of congenital abnormalities were found. The study did not reveal any clear adverse reactions due to in utero exposure to ciprofloxacin.

No differences in the rates of prematurity, spontaneous abortions, or birth weight were seen in women exposed to ciprofloxacin during pregnancy. However, these small postmarketing epidemiology studies, of which most experience is from short term, first trimester exposure, are insufficient to evaluate the risk for less common defects or to permit reliable and definitive conclusions regarding the safety of ciprofloxacin in pregnant women and their developing fetuses.

Animal Data

Developmental toxicology studies have been performed with ciprofloxacin in rats, mice, and rabbits. In rats and mice, oral doses up to 100 mg/kg administered during organogenesis (Gestation Days, GD, 6-17) were not associated with adverse developmental outcomes, including embryofetal toxicity or malformations. In rats and mice, a 100 mg/kg dose is approximately 0.6 and 0.3 times the maximum daily human oral dose (1500 mg/day) based upon body surface area, respectively. In a series of rabbit developmental toxicology studies, does received oral or intravenous ciprofloxacin for one of the following 5 day periods: GD 6 to 10, GD 10 to 14, or GD 14 to 18, intended to cover the period of organogenesis. This was an attempt to mitigate the gastrointestinal intolerance observed in rabbits that receive antibacterials manifested by reduced maternal food consumption and weight loss, that can lead to embryofetal resorption or spontaneous abortion. An oral ciprofloxacin dose of 100 mg/kg (approximately 1.3 times the highest recommended clinical oral dose based on body surface area) caused excessive maternal toxicity confounding evaluation of the fetuses. A 30 mg/kg oral dose (approximately 0.4 times the highest recommended clinical oral dose) was associated with suppression of maternal and fetal body weight gain, but fetal malformations were not observed. Intravenous administration of doses up to 20 mg/kg (approximately 0.3 times the highest recommended clinical oral dose based upon body surface area) to pregnant rabbits was not maternally toxic and neither embryofetal toxicity nor fetal malformations were observed.

In peri- and post-natal studies, rats received ciprofloxacin doses up to 200 mg/kg/day (oral) or up to 30 mg/kg/day (subcutaneous) from GD 16 to 22 days postpartum. The 200 mg/kg dose is approximately 1.3-times the maximum recommended clinical oral dose based on body surface area. Neither maternal toxicity nor adverse effects on growth and development of the pups were observed, including no sign of arthropathy on the rear leg joints of the pups. Ciprofloxacin and other quinolones have been shown to cause arthropathy in immature animals of most species tested when administered directly [see Warnings and Precautions (5.13) and Nonclinical Toxicology 13.2].

8.2 Lactation

Risk Summary

Published literature reports that ciprofloxacin is present in human milk following intravenous and oral administration. There is no information regarding effects of CIPRO on milk production or the breastfed infant. Because of the potential risk of serious adverse reactions in breastfed infants, including arthropathy shown in juvenile animal studies [see Use in Specific Populations (8.4), (Clinical Considerations)], for most indications a lactating woman may consider pumping and discarding breast milk during treatment with CIPRO and an additional two days (five half-lives) after the last dose. Alternatively, advise a woman that breastfeeding is not recommended during treatment with CIPRO and for an additional two days (five half-lives) after the last dose.

However, for inhalation anthrax (post exposure), during an incident resulting in exposure to anthrax, the risk-benefit assessment of continuing breastfeeding while the mother (and potentially the infant) is (are) on CIPRO may be acceptable [see Dosage and Administration (2.2), Pediatric Use (8.4), and Clinical Studies (14.2)]. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for CIPRO and any potential adverse effects on the breastfed child from CIPRO or from the underlying maternal condition.

Clinical Considerations

Ciprofloxacin may cause intestinal flora alteration of the breastfeeding infant. Advise a woman to monitor the breastfed infant for loose or bloody stools and candidiasis (thrush, diaper rash).

8.4 Pediatric Use

Although effective in clinical trials, CIPRO is not a drug of first choice in the pediatric population due to an increased incidence of adverse reactions compared to controls. Quinolones, including CIPRO, cause arthropathy (arthralgia, arthritis), in juvenile animals [see Warnings and Precautions (5.13) and Nonclinical Toxicology (13.2)].

Complicated Urinary Tract Infection and Pyelonephritis

CIPRO is indicated for the treatment of cUTI and pyelonephritis due to Escherichia coli in pediatric patients 1 to 17 years of age. Although effective in clinical trials, CIPRO is not a drug of first choice in the pediatric population due to an increased incidence of adverse reactions compared to the controls, including events related to joints and/or surrounding tissues [see Adverse Reactions (6.1) and Clinical Studies (14.1)].

Inhalational Anthrax (Post-Exposure)

CIPRO is indicated in pediatric patients from birth to 17 years of age, for inhalational anthrax (post-exposure). The risk-benefit assessment indicates that administration of ciprofloxacin to pediatric patients is appropriate [see Dosage and Administration (2.2) and Clinical Studies (14.2)].

Plague

CIPRO is indicated in pediatric patients from birth to 17 years of age, for treatment of plague, including pneumonic and septicemic plague due to Yersinia pestis (Y. pestis) and prophylaxis for plague. Efficacy studies of CIPRO could not be conducted in humans with pneumonic plague for feasibility reasons. Therefore, approval of this indication was based on an efficacy study conducted in animals. The risk-benefit assessment indicates that administration of CIPRO to pediatric patients is appropriate [see Indications and Usage (1.8), Dosage and Administration (2.2) and Clinical Studies (14.3)].

8.5 Geriatric Use

Geriatric patients are at increased risk for developing severe tendon disorders including tendon rupture when being treated with a fluoroquinolone such as CIPRO. This risk is further increased in patients receiving concomitant corticosteroid therapy. Tendinitis or tendon rupture can involve the Achilles, hand, shoulder, or other tendon sites and can occur during or after completion of therapy; cases occurring up to several months after fluoroquinolone treatment have been reported. Caution should be used when prescribing CIPRO to elderly patients especially those on corticosteroids. Patients should be informed of this potential adverse reaction and advised to discontinue CIPRO and contact their healthcare provider if any symptoms of tendinitis or tendon rupture occur. [see Boxed Warning, Warnings and Precautions (5.2), and Adverse Reactions (6.2)].

Epidemiologic studies report an increased rate of aortic aneurysm and dissection within two months following use of fluoroquinolones, particularly in elderly patients [see Warnings and Precautions (5.9)].

In a retrospective analysis of 23 multiple-dose controlled clinical trials of CIPRO encompassing over 3500 ciprofloxacin-treated patients, 25% of patients were greater than or equal to 65 years of age and 10% were greater than or equal to 75 years of age. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals on any drug therapy cannot be ruled out. Ciprofloxacin is known to be substantially excreted by the kidney, and the risk of adverse reactions may be greater in patients with impaired renal function. No alteration of dosage is necessary for patients greater than 65 years of age with normal renal function. However, since some older individuals experience reduced renal function by virtue of their advanced age, care should be taken in dose selection for elderly patients, and renal function monitoring may be useful in these patients [see Dosage and Administration (2.3) and Clinical Pharmacology (12.3)].

In general, elderly patients may be more susceptible to drug-associated effects on the QT interval. Therefore, precaution should be taken when using CIPRO with concomitant drugs that can result in prolongation of the QT interval (for example, class IA or class III antiarrhythmics) or in patients with risk factors for torsade de pointes (for example, known QT prolongation, uncorrected hypokalemia) [see Warnings and Precautions (5.12)].

8.6 Renal Impairment

Ciprofloxacin is eliminated primarily by renal excretion; however, the drug is also metabolized and partially cleared through the biliary system of the liver and through the intestine. These alternative pathways of drug elimination appear to compensate for the reduced renal excretion in patients with renal impairment. Nonetheless, some modification of dosage is recommended, particularly for patients with severe renal dysfunction [see Dosage and Administration (2.3) and Clinical Pharmacology (12.3)].

8.7 Hepatic Impairment

In preliminary studies in patients with stable chronic liver cirrhosis, no significant changes in ciprofloxacin pharmacokinetics have been observed. The pharmacokinetics of ciprofloxacin in patients with acute hepatic insufficiency, have not been studied.

10 OVERDOSAGE

In the event of acute overdosage, reversible renal toxicity has been reported in some cases. Empty the stomach by inducing vomiting or by gastric lavage. Observe the patient carefully and give supportive treatment, including monitoring of renal function, urinary pH and acidify, if required, to prevent crystalluria and administration of magnesium, aluminum, or calcium containing antacids which can reduce the absorption of ciprofloxacin. Adequate hydration must be maintained. Only a small amount of ciprofloxacin (less than 10%) is removed from the body after hemodialysis or peritoneal dialysis.

11 DESCRIPTION

CIPRO (ciprofloxacin hydrochloride) Tablets and CIPRO (ciprofloxacin) Oral Suspension are synthetic antimicrobial agents for oral administration. Ciprofloxacin hydrochloride, USP, a fluoroquinolone, is the monohydrochloride monohydrate salt of 1-cyclopropyl-6-fluoro-1, 4-dihydro-4-oxo-7-(1-piperazinyl)-3-quinolinecarboxylic acid. It is a faintly yellowish to light yellow crystalline substance with a molecular weight of 385.8. Its empirical formula is C17H18FN3O3HClH2O and its chemical structure is as follows:

chem struc 1

Ciprofloxacin is 1-cyclopropyl-6-fluoro-1,4-dihydro-4-oxo-7-(1-piperazinyl)-3-quinolinecarboxylic acid. Its empirical formula is C17H18FN3O3 and its molecular weight is 331.4. It is a faintly yellowish to light yellow crystalline substance and its chemical structure is as follows:

chem struc 2

CIPRO film-coated tablets are available in 250 mg and 500 mg (ciprofloxacin equivalent) strengths. Each CIPRO film-coated tablet contains 250 mg (equivalent to 291 mg ciprofloxacin hydrochloride monohydrate) or 500 mg of ciprofloxacin (equivalent to 582 mg ciprofloxacin hydrochloride monohydrate) CIPRO tablets are white to slightly yellowish. The inactive ingredients are cornstarch, crospovidone, hypromellose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, silicon dioxide, and titanium dioxide.

CIPRO Oral Suspension is available in 5% (5 g ciprofloxacin in 100 mL) and 10% (10 g ciprofloxacin in 100 mL) strengths. CIPRO Oral Suspension is a white to slightly yellowish suspension with strawberry flavor which may contain yellow-orange droplets. It is composed of ciprofloxacin microcapsules and diluent which are mixed prior to dispensing [see Dosage and Administration (2.5)]. The components of the suspension have the following compositions:

  • Microcapsules–ciprofloxacin, hypromellose, magnesium stearate, methacrylic acid copolymer, Polysorbate 20 and povidone.
  • Diluent–medium-chain triglycerides, sucrose, soy-lecithin, water, and strawberry flavor.
  • Five (5) mL of 5% suspension contains approximately 1.4 g of sucrose and 5 mL of 10% suspension contains approximately 1.3 g of sucrose.
chem struc 1
chem struc 2

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Ciprofloxacin is a member of the fluoroquinolone class of antibacterial agents [see Microbiology (12.4)].

12.3 Pharmacokinetics

Absorption

The absolute bioavailability of ciprofloxacin when given as an oral tablet is approximately 70% with no substantial loss by first pass metabolism. Ciprofloxacin maximum serum concentrations (Cmax) and area under the curve (AUC) are shown in the chart for the 250 mg to 1000 mg dose range (Table 12).

Table 12: Ciprofloxacin Cmax and AUC Following Adminstration of Single Doses of CIPRO Tablets to Healthy Subjects

Dose (mg)

  •   Cmax

AUC
(mcghr/mL)

250

1.2

4.8

500

2.4

11.6

750

4.3

20.2

1000

5.4

30.8

Maximum serum concentrations are attained 1 to 2 hours after oral dosing. Mean concentrations 12 hours after dosing with 250, 500, or 750 mg are 0.1, 0.2, and 0.4 mcg/mL, respectively. The serum elimination half-life in subjects with normal renal function is approximately 4 hours. Serum concentrations increase proportionately with doses up to 1000 mg.

A 500 mg oral dose given every 12 hours has been shown to produce AUC equivalent to that produced by an intravenous infusion of 400 mg CIPRO given over 60 minutes every 12 hours. A 750 mg oral dose given every 12 hours has been shown to produce an AUC at steady-state equivalent to that produced by an intravenous infusion of 400 mg given over 60 minutes every 8 hours. A 750 mg oral dose results in a Cmax similar to that observed with a 400 mg intravenous dose (Table 13). A 250 mg oral dose given every 12 hours produces an AUC equivalent to that produced by an infusion of 200 mg CIPRO given every 12 hours.

Table 13: Steady-state Pharmacokinetic Parameters Following Multiple Oral and Intravenous Doses (Adults)

Parameters

500 mg

400 mg

750 mg

400 mg

every 12 hours, orally

every 12 hours, intravenously

every 12 hours, orally

every 8 hours, intravenously

AUC0-24h,ss (µgh/mL)

27.4AUC0-12h x 2

25.4*

31.6*

32.9**

Cmax,ss (µg/mL)

2.97

4.56

3.59

4.07

Food

When CIPRO Tablet is given concomitantly with food, there is a delay in the absorption of the drug, resulting in peak concentrations that occur closer to 2 hours after dosing rather than 1 hour whereas there is no delay observed when CIPRO Suspension is given with food. The overall absorption of CIPRO Tablet or CIPRO Suspension, however, is not substantially affected. The pharmacokinetics of ciprofloxacin given as the suspension are also not affected by food. Avoid concomitant administration of CIPRO with dairy products (like milk or yogurt) or calcium-fortified juices alone since decreased absorption is possible; however, CIPRO may be taken with a meal that contains these products

With oral administration, a 500 mg dose, given as 10 mL of the 5% CIPRO Suspension (containing 250 mg ciprofloxacin/5mL) is bioequivalent to the 500 mg tablet. A 10 mL volume of the 5% CIPRO Suspension (containing 250 mg ciprofloxacin/5mL) is bioequivalent to a 5 mL volume of the 10% CIPRO Suspension (containing 500 mg ciprofloxacin/5mL).

Distribution

The binding of ciprofloxacin to serum proteins is 20% to 40% which is not likely to be high enough to cause significant protein binding interactions with other drugs.

After oral administration, ciprofloxacin is widely distributed throughout the body. Tissue concentrations often exceed serum concentrations in both men and women, particularly in genital tissue including the prostate. Ciprofloxacin is present in active form in the saliva, nasal and bronchial secretions, mucosa of the sinuses, sputum, skin blister fluid, lymph, peritoneal fluid, bile, and prostatic secretions. Ciprofloxacin has also been detected in lung, skin, fat, muscle, cartilage, and bone. The drug diffuses into the cerebrospinal fluid (CSF); however, CSF concentrations are generally less than 10% of peak serum concentrations. Low levels of the drug have been detected in the aqueous and vitreous humors of the eye.

Metabolism

Four metabolites have been identified in human urine which together account for approximately 15% of an oral dose. The metabolites have antimicrobial activity, but are less active than unchanged ciprofloxacin. Ciprofloxacin is an inhibitor of human cytochrome P450 1A2 (CYP1A2) mediated metabolism. Co-administration of ciprofloxacin with other drugs primarily metabolized by CYP1A2 results in increased plasma concentrations of these drugs and could lead to clinically significant adverse events of the co-administered drug [see Contraindications (4.2), Warnings and Precautions (5.10, 5.16), and Drug Interactions (7)].

Excretion

The serum elimination half-life in subjects with normal renal function is approximately 4 hours. Approximately 40 to 50% of an orally administered dose is excreted in the urine as unchanged drug. After a 250 mg oral dose, urine concentrations of ciprofloxacin usually exceed 200 mcg/mL during the first two hours and are approximately 30 mcg/mL at 8 to 12 hours after dosing. The urinary excretion of ciprofloxacin is virtually complete within 24 hours after dosing. The renal clearance of ciprofloxacin, which is approximately 300 mL/minute, exceeds the normal glomerular filtration rate of 120 mL/minute. Thus, active tubular secretion would seem to play a significant role in its elimination. Co-administration of probenecid with ciprofloxacin results in about a 50% reduction in the ciprofloxacin renal clearance and a 50% increase in its concentration in the systemic circulation.

Although bile concentrations of ciprofloxacin are several fold higher than serum concentrations after oral dosing, only a small amount of the dose administered is recovered from the bile as unchanged drug. An additional 1% to 2% of the dose is recovered from the bile in the form of metabolites. Approximately 20% to 35% of an oral dose is recovered from the feces within 5 days after dosing. This may arise from either biliary clearance or transintestinal elimination.

Specific Populations

Elderly

Pharmacokinetic studies of the oral (single dose) and intravenous (single and multiple dose) forms of ciprofloxacin indicate that plasma concentrations of ciprofloxacin are higher in elderly subjects (older than 65 years) as compared to young adults. Although the Cmax is increased 16% to 40%, the increase in mean AUC is approximately 30%, and can be at least partially attributed to decreased renal clearance in the elderly. Elimination half-life is only slightly (~20%) prolonged in the elderly. These differences are not considered clinically significant [see Use in Specific Populations (8.5)].

Renal Impairment

In patients with reduced renal function, the half-life of ciprofloxacin is slightly prolonged. Dosage adjustments may be required [see Use in Specific Populations (8.6) and Dosage and Administration (2.3)].

Hepatic Impairment

In preliminary studies in patients with stable chronic liver cirrhosis, no significant changes in ciprofloxacin pharmacokinetics have been observed. The kinetics of ciprofloxacin in patients with acute hepatic insufficiency, have not been fully studied.

Pediatrics

Table 14: Estimated AUC0–24,ss and Cmax,ss for Intravenous Treatment (1-h infusion) in Pediatric Patients Following a Multiple Dosing Regimen of 10 mg/kg, Three Times Daily

Age

AUC0–24,ss
(mg h/L)

Cmax,ss
(mg/L)

Less than1 year

30.9

2.8

1 to less than 2 years

27.8

3.6

2 to less than 6 years

28.9

2.7

6 to less than 12 years

20.4

2.0

These values are within the range reported for adults at therapeutic doses. Based on population pharmacokinetic analysis of pediatric patients with various infections, the predicted mean half-life in children is approximately 4 hours –5 hours, and the bioavailability of the oral suspension is approximately 60%.

Drug-Drug Interactions

Antacids

Concurrent administration of antacids containing magnesium hydroxide or aluminum hydroxide may reduce the bioavailability of ciprofloxacin by as much as 90% [see Dosage and Administration (2.4) and Drug Interactions (7)].

Histamine H2-receptor antagonists

Histamine H2-receptor antagonists appear to have no significant effect on the bioavailability of ciprofloxacin.

Metronidazole

The serum concentrations of ciprofloxacin and metronidazole were not altered when these two drugs were given concomitantly.

Tizanidine

In a pharmacokinetic study, systemic exposure of tizanidine (4 mg single dose) was significantly increased (Cmax 7-fold, AUC 10-fold) when the drug was given concomitantly with CIPRO (500 mg twice a day for 3 days). Concomitant administration of tizanidine and CIPRO is contraindicated due to the potentiation of hypotensive and sedative effects of tizanidine [see Contraindications (4.2)].

Ropinirole

In a study conducted in 12 patients with Parkinson’s disease who were administered 6 mg ropinirole once daily with 500 mg CIPRO twice-daily, the mean Cmax and mean AUC of ropinirole were increased by 60% and 84%, respectively. Monitoring for ropinirole-related adverse reactions and appropriate dose adjustment of ropinirole is recommended during and shortly after co-administration with CIPRO [see Warnings and Precautions (5.10)].

Clozapine

Following concomitant administration of 250 mg CIPRO with 304 mg clozapine for 7 days, serum concentrations of clozapine and N-desmethylclozapine were increased by 29% and 31%, respectively. Careful monitoring of clozapine associated adverse reactions and appropriate adjustment of clozapine dosage during and shortly after co-administration with CIPRO are advised.

Sildenafil

Following concomitant administration of a single oral dose of 50 mg sildenafil with 500 mg CIPRO to healthy subjects, the mean Cmax and mean AUC of sildenafil were both increased approximately two-fold. Use sildenafil with caution when co-administered with CIPRO due to the expected two-fold increase in the exposure of sildenafil upon co-administration of CIPRO.

Duloxetine

In clinical studies it was demonstrated that concomitant use of duloxetine with strong inhibitors of the CYP450 1A2 isozyme such as fluvoxamine, may result in a 5-fold increase in mean AUC and a 2.5-fold increase in mean Cmax of duloxetine.

Lidocaine

In a study conducted in 9 healthy volunteers, concomitant use of 1.5 mg/kg IV lidocaine with CIPRO 500 mg twice daily resulted in an increase of lidocaine Cmax and AUC by 12% and 26%, respectively. Although lidocaine treatment was well tolerated at this elevated exposure, a possible interaction with CIPRO and an increase in adverse reactions related to lidocaine may occur upon concomitant administration.

Metoclopramide

Metoclopramide significantly accelerates the absorption of oral ciprofloxacin resulting in a shorter time to reach maximum plasma concentrations. No significant effect was observed on the bioavailability of ciprofloxacin.

Omeprazole

When CIPRO was administered as a single 1000 mg dose concomitantly with omeprazole (40 mg once daily for three days) to 18 healthy volunteers, the mean AUC and Cmax of ciprofloxacin were reduced by 20% and 23%, respectively. The clinical significance of this interaction has not been determined.

12.4 Microbiology

Mechanism of Action

The bactericidal action of ciprofloxacin results from inhibition of the enzymes topoisomerase II (DNA gyrase) and topoisomerase IV (both Type II topoisomerases), which are required for bacterial DNA replication, transcription, repair, and recombination.

Mechanism of Resistance

The mechanism of action of fluoroquinolones, including ciprofloxacin, is different from that of penicillins, cephalosporins, aminoglycosides, macrolides, and tetracyclines; therefore, microorganisms resistant to these classes of drugs may be susceptible to ciprofloxacin. Resistance to fluoroquinolones occurs primarily by either mutations in the DNA gyrases, decreased outer membrane permeability, or drug efflux. In vitro resistance to ciprofloxacin develops slowly by multiple step mutations. Resistance to ciprofloxacin due to spontaneous mutations occurs at a general frequency of between < 10-9 to 1x10-6 .

Cross Resistance

There is no known cross-resistance between ciprofloxacin and other classes of antimicrobials.

Ciprofloxacin has been shown to be active against most isolates of the following bacteria, both in vitro and in clinical infections [see Indications and Usage (1)].

Gram-positive bacteria

Bacillus anthracis

Enterococcus faecalis

Staphylococcus aureus (methicillin-susceptible isolates only)

Staphylococcus epidermidis (methicillin-susceptible isolates only)

Staphylococcus saprophyticus

Streptococcus pneumoniae

Streptococcus pyogenes

Gram-negative bacteria

Campylobacter jejuni

Citrobacter koseri

Citrobacter freundii

Enterobacter cloacae

Escherichia coli

Haemophilus influenzae

Haemophilus parainfluenzae

Klebsiella pneumoniae

Moraxella catarrhalis

Morganella morganii

Neisseria gonorrhoeae

Proteus mirabilis

Proteus vulgaris

Providencia rettgeri

Providencia stuartii

Pseudomonas aeruginosa

Salmonella typhi

Serratia marcescens

Shigella boydii

Shigella dysenteriae

Shigella flexneri

Shigella sonnei

Yersinia pestis

The following in vitro data are available, but their clinical significance is unknown. At least 90 percent of the following bacteria exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for ciprofloxacin against isolates of similar genus or organism group. However, the efficacy of ciprofloxacin in treating clinical infections caused by these bacteria has not been established in adequate and well-controlled clinical trials.

Gram-positive bacteria

Staphylococcus haemolyticus (methicillin-susceptible isolates only)

Staphylococcus hominis (methicillin-susceptible isolates only)

Gram-negative bacteria

Acinetobacter lwoffi

Aeromonas hydrophila

Edwardsiella tarda

Enterobacter aerogenes

Klebsiella oxytoca

Legionella pneumophila

Pasteurella multocida

Salmonella enteritidis

Vibrio cholerae

Vibrio parahaemolyticus

Vibrio vulnificus

Yersinia enterocolitica

Susceptibility Testing

For specific information regarding susceptibility test interpretive criteria and associated test methods and quality control standards recognized by FDA for this drug, please see: https://www.fda.gov/STIC.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Eight in vitro mutagenicity tests have been conducted with ciprofloxacin, and the test results are listed below:

  • Salmonella/Microsome Test (Negative)
  • E. coli DNA Repair Assay (Negative)
  • Mouse Lymphoma Cell Forward Mutation Assay (Positive)
  • Chinese Hamster V79 Cell HGPRT Test (Negative)
  • Syrian Hamster Embryo Cell Transformation Assay (Negative)
  • Saccharomyces cerevisiae Point Mutation Assay (Negative)
  • Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay (Negative)
  • Rat Hepatocyte DNA Repair Assay (Positive)