Ciprofloxacin (Tablets, Solution, Drops, Concentrate) Instructions for Use

ATC Code

J01MA02 (Ciprofloxacin)

Active Substance

Ciprofloxacin (Rec.INN registered by WHO)

Clinical-Pharmacological Group

Antibacterial drug of the fluoroquinolone group

Pharmacotherapeutic Group

Systemic antibacterial agents; quinolone derivatives; fluoroquinolones

Pharmacological Action

A broad-spectrum antimicrobial agent, a fluoroquinolone derivative.

It inhibits bacterial DNA gyrase (topoisomerases II and IV, responsible for the supercoiling process of chromosomal DNA around nuclear RNA, which is necessary for reading genetic information), disrupts DNA synthesis, growth, and division of bacteria; causes pronounced morphological changes (including of the cell wall and membranes) and rapid death of the bacterial cell.

It acts bactericidally on gram-negative organisms during both the resting and division phases (as it affects not only DNA gyrase but also causes lysis of the cell wall), and on gram-positive microorganisms only during the division phase.

Low toxicity to the cells of the macroorganism is explained by the absence of DNA gyrase in them. During the administration of ciprofloxacin, no parallel development of resistance to other antibiotics not belonging to the group of gyrase inhibitors occurs, which makes it highly effective against bacteria that are resistant, for example, to aminoglycosides, penicillins, cephalosporins, tetracyclines, and many other antibiotics.

The following are sensitive to ciprofloxacin: gram-negative aerobic bacteria – enterobacteria (Escherichia coli, Salmonella spp., Shigella spp., Citrobacter spp., Klebsiella spp., Enterobacter spp., Proteus mirabilis, Proteus vulgaris, Serratia marcescens, Hafnia alvei, Edwardsiella tarda, Providencia spp., Morganella morganii, Vibrio spp., Yersinia spp.); other gram-negative bacteria (Haemophilus spp., Pseudomonas aeruginosa, Moraxella catarrhalis, Aeromonas spp., Pasteurella multocida, Plesiomonas shigelloides, Campylobacter jejuni, Neisseria spp.); some intracellular pathogens (Legionella pneumophila, Brucella spp., Chlamydia trachomatis, Listeria monocytogenes, Mycobacterium tuberculosis, Mycobacterium kansasii, Corynebacterium diphtheriae); gram-positive aerobic bacteria – Staphylococcus spp. (Staphylococcus aureus, Staphylococcus haemolyticus, Staphylococcus hominis, Staphylococcus saprophyticus), Streptococcus spp. (Streptococcus pyogenes, Streptococcus agalactiae).

Most staphylococci resistant to methicillin are also resistant to ciprofloxacin. The sensitivity of Streptococcus pneumoniae, Enterococcus faecalis, Mycobacterium avium (located intracellularly) is moderate (high concentrations are required for their suppression).

The following are resistant to ciprofloxacin: Bacteroides fragilis, Pseudomonas cepacia, Pseudomonas maltophilia, Ureaplasma urealyticum, Clostridium difficile, Nocardia asteroides. It is ineffective against Treponema pallidum.

Resistance develops extremely slowly because, on the one hand, practically no persisting microorganisms remain after the action of ciprofloxacin, and on the other hand, bacterial cells lack enzymes that inactivate it.

Pharmacokinetics

After IV administration, C_max of ciprofloxacin is reached at the end of the infusion. The pharmacokinetics of ciprofloxacin are linear in the dose range up to 400 mg. When administered IV 2-3 times/day, no accumulation of ciprofloxacin and its metabolites was noted.

The binding of ciprofloxacin to plasma proteins is 20-30%; the active substance is present in the plasma mainly in a non-ionized form. Ciprofloxacin is freely distributed in body tissues and fluids. V_d in the body is 2-3 L/kg. The concentration of ciprofloxacin in tissues significantly exceeds the concentration in blood serum. It is metabolized in the liver. Four metabolites of ciprofloxacin can be detected in the blood in low concentrations: diethylciprofloxacin (M1), sulfociprofloxacin (M2), oxociprofloxacin (M3), formylciprofloxacin (M4); three of which (M1-M3) exhibit antibacterial activity in vitro comparable to the antibacterial activity of nalidixic acid. The in vitro antibacterial activity of metabolite M4, present in smaller quantities, more closely corresponds to the activity of norfloxacin. Ciprofloxacin is eliminated from the body mainly by the kidneys through glomerular filtration and tubular secretion; a small amount is eliminated through the gastrointestinal tract. Renal clearance is 0.18-0.3 L/h/kg, total clearance is 0.48-0.60 L/h/kg. Approximately 1% of the administered dose is excreted in the bile. Ciprofloxacin is present in bile in high concentrations. In patients with unchanged renal function, T_1/2 is usually 3-5 hours. In case of impaired renal function, T_1/2 increases.

Indications

Uncomplicated and complicated infections caused by microorganisms sensitive to ciprofloxacin.

Adults

Infections of the respiratory tract – pneumonia caused by Klebsiella spp., Enterobacter spp., Proteus spp., Escherichia coli, Pseudomonas aeruginosa, Haemophilus spp., Moraxella catarrhalis, Legionella spp., Staphylococcus spp.; middle ear infections (otitis media), especially if these infections are caused by Staphylococcus spp. and gram-negative microorganisms, including Pseudomonas aeruginosa; eye infections; kidney infections and/or complicated urinary tract infections; genital infections, including adnexitis, gonorrhea, prostatitis; abdominal infections (bacterial infections of the gastrointestinal tract, biliary tract, peritonitis); skin and soft tissue infections; bone and joint infections; sepsis; infections or prevention of infections in patients with reduced immunity (patients taking immunosuppressants or patients with neutropenia); selective intestinal decontamination in patients with reduced immunity; prevention and treatment of the pulmonary form of anthrax (infection with Bacillus anthracis).

For the treatment of the following infectious and inflammatory diseases, Ciprofloxacin may be used only as an alternative to other antimicrobial drugs: acute sinusitis; uncomplicated urinary tract infections.

Children

Treatment of complications caused by Pseudomonas aeruginosa in children with cystic fibrosis of the lungs from 5 to 17 years old; prevention and treatment of the pulmonary form of anthrax (infection with Bacillus anthracis).

The use of ciprofloxacin in children should be initiated only after assessing the benefit/risk ratio due to the possible adverse effect on joints and periarticular tissues.

ICD codes

Dosage Regimen

Solution

The drug should be administered intravenously by drip over 30 minutes (200 mg dose) and 60 minutes (400 mg dose). The infusion solution can be combined with 0.9% sodium chloride solution, Ringer’s solution, 5% and 10% dextrose (glucose) solution, 10% fructose solution, a solution containing 5% dextrose with 0.225% or 0.45% sodium chloride solution.

The dose of Ciprofloxacin depends on the severity of the disease, the type of infection, the condition of the body, age, weight, and renal function of the patient.

A single dose is 200 mg, for severe infections – 400 mg. Frequency of administration – 2 times/day; duration of treatment – 1-2 weeks, if necessary, the course of treatment can be extended.

For acute gonorrhea, the drug is prescribed IV as a single dose of 100 mg.

For prevention of postoperative infections – 30-60 minutes before surgery IV at a dose of 200-400 mg.

For patients with severe renal failure (CrCl<20 ml/min/1.73 m²), it is necessary to prescribe half the daily dose.

Tablets

Individual, depending on the indications, clinical situation, and patient age.

Adults are prescribed 250-750 mg 2 times/day; children – 15-20 mg/kg 2 times/day.

Drops

For instillation into the eyes or into the external auditory canal in the appropriate dosage form.

Do not perform subconjunctival or anterior chamber of the eye instillations.

Used according to special schemes depending on the indications.

Concentrate

Individual, depending on the indications, clinical situation, and patient age.

A single dose for adults is 200-400 mg, frequency of administration – 2 times/day; for children – 10 mg/kg, frequency of administration – 2-3 times/day.

Adverse Reactions

Infectious and parasitic diseases – uncommon: mycotic superinfections; rare: pseudomembranous colitis (in very rare cases with a possible fatal outcome).

From the hematopoietic system: uncommon: eosinophilia; rare: leukopenia, anemia, neutropenia, leukocytosis, thrombocytopenia, thrombocythemia. Very rare: hemolytic anemia, agranulocytosis, pancytopenia (life-threatening), bone marrow depression (life-threatening).

Allergic reactions – uncommon: urticaria; rare: allergic edema/angioedema; very rare: anaphylactic reactions, anaphylactic shock (life-threatening), serum sickness.

From the endocrine system – frequency unknown: syndrome of inappropriate ADH secretion.

From metabolism – uncommon: decreased appetite and food intake; rare: hyperglycemia, hypoglycemia; frequency unknown: severe hypoglycemia, up to the development of hypoglycemic coma, especially in elderly patients, patients with diabetes mellitus taking oral hypoglycemic drugs or insulin.

Mental disorders – uncommon: psychomotor hyperactivity/agitation; rare: confusion and disorientation, anxiety, nightmares, depression, hallucinations; very rare: psychotic reactions (increase in self-harming behavior such as suicidal actions/thoughts, as well as suicide attempt or completed suicide); frequency unknown: attention disturbances, nervousness, memory impairment, delirium.

From the nervous system – uncommon: headache, dizziness, sleep disorders, taste disturbances; rare: paresthesia and dysesthesia, hypoesthesia, tremor, convulsions (including epileptic seizures), vertigo; very rare: migraine, impaired coordination, impaired sense of smell, hyperesthesia, intracranial hypertension (cerebral pseudotumor symptoms); frequency unknown: peripheral neuropathy and polyneuropathy.

From the organ of vision – rare: visual disturbances; very rare: impaired color perception.

From the organ of hearing and labyrinthine disorders – rare: tinnitus, hearing loss; very rare: hearing disorders.

From the cardiovascular system – rare: tachycardia, vasodilation, decreased blood pressure, fainting; very rare: vasculitis; frequency unknown: QT interval prolongation, ventricular arrhythmias (including torsades de pointes, more often in patients predisposed to QT interval prolongation).

From the respiratory system – rare: breathing disorders (including bronchospasm).

From the digestive system – common: nausea, diarrhea; uncommon: vomiting, abdominal pain, dyspepsia, flatulence; very rare: pancreatitis.

From the liver and biliary tract – uncommon: increased activity of liver transaminases, increased bilirubin concentration; rare: liver function disorders, jaundice, hepatitis (non-infectious); very rare: liver tissue necrosis (in extremely rare cases progressing to life-threatening liver failure).

From the skin and subcutaneous tissues – uncommon: rash, itching, urticaria; rare: photosensitivity, blistering; very rare: petechiae, erythema multiforme minor, erythema nodosum, Stevens-Johnson syndrome (malignant exudative erythema), including potentially life-threatening; Lyell’s syndrome (toxic epidermal necrolysis), including potentially life-threatening; frequency unknown: acute generalized pustular exanthema.

From the musculoskeletal system – uncommon: arthralgia; rare: myalgia, arthritis, increased muscle tone, muscle cramps; very rare: muscle weakness, tendinitis, tendon rupture (primarily Achilles), exacerbation of myasthenia gravis symptoms.

From the kidneys and urinary tract – uncommon: renal function disorders; rare: renal failure, hematuria, crystalluria, tubulointerstitial nephritis.

General reactions – uncommon: pain syndrome of non-specific etiology, general malaise, fever; rare: edema, hyperhidrosis; very rare: gait disturbance.

From laboratory parameters – uncommon: increased alkaline phosphatase activity; rare: change in prothrombin content, increased amylase activity; frequency unknown: increased INR (in patients receiving vitamin K antagonists).

The frequency of the following adverse reactions with intravenous administration and with step-down therapy with ciprofloxacin (intravenous administration followed by oral administration) is higher than with oral administration Common – vomiting, increased activity of hepatic transaminases, rash; Uncommon – thrombocytopenia, thrombocythemia, confusion and disorientation, hallucinations, paresthesia and dysesthesia, convulsions, vertigo, visual disturbances, hearing loss, tachycardia, vasodilation, decreased blood pressure, reversible liver dysfunction, jaundice, renal failure, edema; Rare – pancytopenia, bone marrow depression, anaphylactic shock, psychotic reactions, migraine, olfactory disturbances, hearing impairment, vasculitis, pancreatitis, liver tissue necrosis, petechiae, tendon rupture.

In children Common – arthropathies. The frequency of arthropathy (arthralgia, arthritis) mentioned above is based on clinical studies in adult patients.

Contraindications

Hypersensitivity to ciprofloxacin or other drugs from the fluoroquinolone group; simultaneous use of ciprofloxacin and tizanidine due to clinically significant side effects (arterial hypotension, drowsiness) associated with an increase in tizanidine plasma concentration; pregnancy, breastfeeding period; children and adolescents under 18 years of age – until the completion of the skeletal formation process for all indications (except for the therapy of complications caused by Pseudomonas aeruginosa in children with cystic fibrosis of the lungs under 5 years of age; prophylaxis and treatment of the pulmonary form of anthrax).

With caution

Epilepsy, lowered seizure threshold (or history of seizures), severe cerebral atherosclerosis, cerebrovascular accident, organic brain lesions or stroke; mental illnesses (depression, psychosis); severe renal and/or hepatic insufficiency; tendon lesions during previous treatment with quinolones; increased risk of QT interval prolongation or development of torsades de pointes arrhythmia (for example, congenital long QT syndrome, heart diseases (heart failure, myocardial infarction, bradycardia), electrolyte imbalance (for example, in hypokalemia, hypomagnesemia); simultaneous use of drugs that prolong the QT interval (including class IA and III antiarrhythmic drugs, tricyclic antidepressants, macrolides, antipsychotics); simultaneous use with inhibitors of the CYP1A2 isoenzyme (including theophylline, methylxanthine, caffeine, duloxetine, clozapine, ropinirole, olanzapine, agomelatine); myasthenia gravis; use in elderly patients, in patients with diabetes mellitus receiving concomitant therapy with oral hypoglycemic drugs (for example, sulfonylurea drugs) or insulin.

Use in Pregnancy and Lactation

Contraindicated for use during pregnancy and breastfeeding.

Use in Hepatic Impairment

Use with caution in severe hepatic insufficiency.

Use in Renal Impairment

Patients with impaired renal function require dosage regimen adjustment.

Pediatric Use

Contraindicated intravenous administration to children and adolescents under 18 years of age – until the completion of the skeletal formation process for all indications (except for the therapy of complications caused by Pseudomonas aeruginosa in children with cystic fibrosis of the lungs under 5 years of age; prophylaxis and treatment of the pulmonary form of anthrax).

Geriatric Use

In elderly patients, Ciprofloxacin should be used in lower doses, depending on the severity of the disease and creatinine clearance.

Special Precautions

When treating severe infections, staphylococcal infections, and infections caused by anaerobic bacteria, Ciprofloxacin should be used in combination with appropriate antibacterial agents.

Ciprofloxacin is not recommended for the treatment of infections caused by Streptococcus pneumoniae due to its limited efficacy against this pathogen.

For genital infections presumably caused by fluoroquinolone-resistant Neisseria gonorrhoeae strains, information on local resistance to ciprofloxacin should be considered and the susceptibility of the pathogen should be confirmed by laboratory tests.

Resistance of Escherichia coli, the most common pathogenic microorganism causing urinary tract infections, to fluoroquinolones varies depending on the region of the Russian Federation. When prescribing, it is recommended to take into account the local prevalence of Escherichia coli resistance to fluoroquinolones.

Ciprofloxacin has an effect on QT interval prolongation. Given that women have a longer average QT interval compared to men, they are more sensitive to drugs that cause QT interval prolongation. Elderly patients also have increased sensitivity to the action of drugs that cause QT interval prolongation. Ciprofloxacin should be used with caution in combination with drugs that prolong the QT interval (for example, class IA and III antiarrhythmic drugs, tricyclic antidepressants, macrolides, and antipsychotic drugs) or in patients with an increased risk of QT interval prolongation or development of torsades de pointes arrhythmia (for example, with congenital long QT syndrome, corrected electrolyte imbalance such as hypokalemia or hypomagnesemia, as well as with heart diseases such as heart failure, myocardial infarction, bradycardia).

Sometimes hypersensitivity reactions, including allergic reactions, may develop after the first dose of ciprofloxacin. In rare cases, anaphylactic reactions up to anaphylactic shock may occur after the first use. In these cases, the use of ciprofloxacin should be stopped immediately and appropriate treatment should be carried out.

If severe and prolonged diarrhea occurs during or after treatment with ciprofloxacin, the diagnosis of pseudomembranous colitis should be excluded, which requires immediate discontinuation of the drug and the appointment of appropriate treatment (vancomycin orally at a dose of 250 mg 4 times/day). In this situation, the use of drugs that suppress intestinal peristalsis is contraindicated.

Cases of liver necrosis and life-threatening liver failure have been reported with the use of ciprofloxacin. If signs of liver disease such as anorexia, jaundice, dark urine, itching, abdominal pain are present, ciprofloxacin should be discontinued. In patients taking Ciprofloxacin and who have had liver disease, a temporary increase in the activity of hepatic transaminases and alkaline phosphatase or cholestatic jaundice may be observed.

Ciprofloxacin should be used with caution in patients with severe myasthenia gravis, as exacerbation of symptoms is possible.

At the first signs of tendinitis (painful swelling in the joint area, inflammation), the use of ciprofloxacin should be discontinued, physical activity should be avoided, as there is a risk of tendon rupture, and a doctor should be consulted. When taking ciprofloxacin, cases of tendinitis and tendon rupture (mainly the Achilles tendon), sometimes bilateral, may occur even within the first 48 hours after the start of therapy. Inflammation and tendon rupture may occur even several months after discontinuation of ciprofloxacin treatment. In elderly patients, patients with renal failure, patients after organ transplantation, simultaneously receiving corticosteroid treatment, there is an increased risk of tendinopathy. Ciprofloxacin should be used with caution in patients with a history of tendon diseases associated with the use of quinolones.

Ciprofloxacin, like other fluoroquinolones, can provoke convulsions and lower the seizure threshold. Patients with epilepsy and those who have had CNS diseases (for example, lowered seizure threshold, history of seizures, cerebrovascular accident, organic brain lesions or stroke) due to the threat of developing side effects from the CNS, Ciprofloxacin should be used only in cases where the expected clinical effect outweighs the possible risk of side effects. If convulsions occur, the use of ciprofloxacin should be discontinued.

Mental reactions may occur even after the first use of fluoroquinolones, including Ciprofloxacin. In rare cases, depression or psychotic reactions may progress to suicidal thoughts and suicide attempts, including completed ones. In case of any side effects from the CNS, including mental disorders, it is necessary to immediately discontinue Ciprofloxacin and initiate appropriate therapy. In these cases, it is recommended to switch to therapy with another antibiotic, other than fluoroquinolones, if possible.

Cases of sensory or sensorimotor polyneuropathy, hypoesthesia, dysesthesia, or weakness have been reported in patients taking fluoroquinolones, including Ciprofloxacin. If symptoms such as pain, burning, tingling, numbness, weakness occur, patients should inform their doctor before continuing the use of the drug.

A photosensitivity reaction may occur with the use of ciprofloxacin, so patients should avoid contact with direct sunlight and UV light. Treatment should be discontinued if symptoms of photosensitivity are observed (for example, skin changes resembling sunburn).

Ciprofloxacin is known to be a moderate inhibitor of CYP1A2 isoenzymes. Caution should be exercised when using ciprofloxacin concomitantly with drugs metabolized by these enzymes, such as theophylline, methylxanthine, caffeine, duloxetine, ropinirole, clozapine, olanzapine, agomelatine – because an increase in the serum concentration of these drugs due to inhibition of their metabolism by ciprofloxacin can cause specific adverse reactions. Simultaneous use of ciprofloxacin and tizanidine is contraindicated.

To avoid the development of crystalluria, exceeding the recommended daily dose is unacceptable, sufficient fluid intake and maintenance of acidic urine reaction are also necessary.

Under in vitro conditions, Ciprofloxacin may interfere with the bacteriological examination of Mycobacterium tuberculosis, inhibiting its growth, which may lead to false-negative results in the diagnosis of this pathogen in patients taking Ciprofloxacin.

As with other fluoroquinolones, changes in blood glucose concentration, including hypo- and hyperglycemia, are possible with the use of ciprofloxacin. During therapy with ciprofloxacin, dysglycemia may occur more often in elderly patients and patients with diabetes mellitus receiving concomitant therapy with oral hypoglycemic drugs (for example, sulfonylurea drugs) or insulin. When using ciprofloxacin in such patients, the risk of hypoglycemia increases, up to hypoglycemic coma. Patients should be informed about the symptoms of hypoglycemia (confusion, dizziness, increased appetite, headache, nervousness, palpitations or rapid pulse, pale skin, sweating, trembling, weakness). If a patient develops hypoglycemia, it is necessary to immediately discontinue treatment with ciprofloxacin and initiate appropriate therapy. In these cases, it is recommended to switch to therapy with another antibiotic, other than fluoroquinolones, if possible. When conducting treatment with ciprofloxacin in elderly patients, in patients with diabetes mellitus, careful monitoring of blood glucose concentration is recommended.

According to epidemiological studies, an increased risk of aortic aneurysm and aortic dissection has been reported after taking fluoroquinolones, especially in elderly patients.

In this regard, fluoroquinolones should be used only after a thorough assessment of the benefit/risk ratio and consideration of other treatment options in patients with a family history of aortic aneurysm or in patients with diagnosed aortic aneurysm and/or aortic dissection or in the presence of other risk factors or conditions predisposing to the development of aortic aneurysm or aortic dissection (for example, Marfan syndrome, vascular type Ehlers-Danlos syndrome, Takayasu’s arteritis, giant cell arteritis, Behçet’s disease, arterial hypertension, atherosclerosis).

In case of sudden abdominal, chest, or back pain, patients should immediately consult a doctor in the emergency department.

Effect on ability to drive vehicles and mechanisms

Fluoroquinolones, including Ciprofloxacin, may impair the ability of patients to drive a car and engage in other potentially hazardous activities requiring increased attention and speed of psychomotor reactions due to the effect on the CNS.

Drug Interactions

Caution should be exercised when using ciprofloxacin concomitantly, as with other fluoroquinolones, in patients receiving drugs that cause QT interval prolongation (for example, class I A or class III antiarrhythmic drugs, tricyclic antidepressants, macrolides, antipsychotic drugs).

Simultaneous oral intake of ciprofloxacin and cation-containing drugs, mineral supplements containing calcium, magnesium, aluminum, iron, sucralfate, antacids, polymeric phosphate compounds (such as sevelamer, lanthanum carbonate) and drugs with high buffering capacity (such as didanosine tablets), containing magnesium, aluminum or calcium, reduces the absorption of ciprofloxacin. In such cases, Ciprofloxacin should be taken either 1-2 hours before or 4 hours after taking these drugs.

This restriction does not apply to medicinal histamine H₂-receptor blockers.

With simultaneous use of ciprofloxacin and omeprazole, a slight decrease in C_max in plasma and a decrease in AUC may be noted.

Simultaneous use of ciprofloxacin and theophylline may cause an undesirable increase in the plasma concentration of theophylline and, accordingly, the occurrence of theophylline-induced adverse events; in very rare cases, these adverse events may be life-threatening to the patient. If simultaneous use of these two drugs is unavoidable, then constant monitoring of the plasma concentration of theophylline is recommended and, if necessary, the dose of theophylline should be reduced.

Simultaneous use of ciprofloxacin and caffeine or pentoxifylline (oxpentifylline) may lead to an increase in the serum concentration of xanthine derivatives.

The combination of very high doses of quinolones (DNA gyrase inhibitors) and some NSAIDs (excluding acetylsalicylic acid) may provoke convulsions.

With simultaneous use of ciprofloxacin and drugs containing cyclosporine, a short-term transient increase in plasma creatinine concentration was observed. In such cases, it is necessary to determine the blood creatinine concentration twice a week.

With simultaneous use of ciprofloxacin and oral hypoglycemic agents, mainly sulfonylurea derivatives (for example, glibenclamide, glimepiride), the development of hypoglycemia is presumably due to the enhancement of the action of oral hypoglycemic agents.

Probenecid slows down the rate of renal excretion of ciprofloxacin. Simultaneous use of ciprofloxacin and drugs containing probenecid leads to an increase in the plasma concentration of ciprofloxacin.

With simultaneous use of ciprofloxacin and phenytoin, a change (increase or decrease) in the plasma content of phenytoin was observed. To avoid a weakening of the anticonvulsant effect of phenytoin due to a decrease in its concentration, as well as to prevent adverse events associated with phenytoin overdose upon discontinuation of ciprofloxacin, it is recommended to monitor phenytoin therapy in patients taking both drugs, including determining the plasma content of phenytoin throughout the entire period of simultaneous use of both drugs and for a short time after the end of combination therapy.

With simultaneous use of methotrexate and ciprofloxacin, the renal tubular transport of methotrexate may be slowed down, which may be accompanied by an increase in the plasma concentration of methotrexate. This may increase the likelihood of developing side effects of methotrexate. In this regard, patients receiving simultaneous therapy with methotrexate and ciprofloxacin should be carefully monitored.

With simultaneous use of ciprofloxacin and tizanidine, an increase in the serum concentration of tizanidine was observed: an increase in C_max by 7 times (from 4 to 21 times), an increase in AUC by 10 times (from 6 to 24 times). An increase in the serum concentration of tizanidine may cause a decrease in blood pressure and drowsiness. Thus, simultaneous use of ciprofloxacin and drugs containing tizanidine is contraindicated.

During clinical studies, it was shown that simultaneous use of duloxetine and potent inhibitors of the CYP1A2 isoenzyme (such as fluvoxamine), may lead to an increase in the AUC and C_max of duloxetine. Despite the lack of clinical data on possible interaction with ciprofloxacin, the possibility of such an interaction can be anticipated with simultaneous use of ciprofloxacin and duloxetine.

Simultaneous use of ropinirole and ciprofloxacin, a moderate inhibitor of the CYP1A2 isoenzyme, leads to an increase in C_max and AUC of ropinirole by 60% and 84%, respectively. Adverse effects of ropinirole should be monitored during its concomitant use with ciprofloxacin and for a short time after the end of combination therapy.

In a study on healthy volunteers, it was found that simultaneous use of drugs containing lidocaine and ciprofloxacin, a moderate inhibitor of the CYP1A2 isoenzyme, leads to a 22% decrease in the clearance of lidocaine when administered intravenously. Despite the good tolerability of lidocaine when used concomitantly with ciprofloxacin, an increase in side effects due to interaction is possible.

With simultaneous use of clozapine and ciprofloxacin at a dose of 250 mg for 7 days, an increase in serum concentrations of clozapine and N-desmethylclozapine by 29% and 31%, respectively, was observed. The patient’s condition should be monitored and, if necessary, the dosage regimen of clozapine should be adjusted during its concomitant use with ciprofloxacin and for a short time after the end of combination therapy.

With simultaneous use in healthy volunteers of ciprofloxacin at a dose of 500 mg and sildenafil at a dose of 50 mg, a 2-fold increase in C_max and AUC of sildenafil was noted. In this regard, the use of this combination is possible only after assessing the benefit/risk ratio.

With simultaneous intake of agomelatine and ciprofloxacin, similar effects can be expected.

With simultaneous use of zolpidem and ciprofloxacin, an increase in the plasma concentration of zolpidem is possible. Simultaneous use of drugs containing these substances is not recommended.

Concomitant use of ciprofloxacin and vitamin K antagonists (for example, warfarin, acenocoumarol, phenprocoumon) may lead to an enhancement of their anticoagulant effect. The magnitude of this effect may vary depending on concomitant infections, age and general condition of the patient, so it is difficult to assess the effect of ciprofloxacin on the increase in INR. INR should be monitored frequently enough during concomitant use of ciprofloxacin and vitamin K antagonists, as well as for a short time after the end of combination therapy.

Concurrent use of ciprofloxacin and dairy products or mineral-fortified beverages (e.g., milk, yogurt, calcium-fortified orange juice) should be avoided, as this may decrease the absorption of ciprofloxacin.

However, calcium from other food sources does not significantly affect the absorption of ciprofloxacin.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.