Authors: Manal Mirreh, MD AND Asif Padiyath, MD – Children’s Hospital of Philadelphia, Philadelphia, PA
A 13-year-old female with Marfan syndrome presents for cardiac MRI. Which of the following class of medications is MOST LIKELY associated with increased risk for aortic dissection and aortic aneurysm in this patient?
EXPLANATION
Aortic dissection is rare in the pediatric population. Prompt diagnosis is crucial due to its high mortality rate of 1% to 2% per hour in the first 48 hours. The risk factors most associated with this condition in the young are inherited disorders of the connective tissue, congenital cardiac disease, severe trauma and chronic hypertension.1
In addition to these risk factors, various medications and recreational drugs are linked to an increased risk of aortic aneurysm and dissection. One notable medication class that increases risk of aortic dissection are fluoroquinolones. Fluoroquinolones are a class of antibiotics that include ciprofloxacin, levofloxacin, and moxifloxacin, which are prescribed to treat a broad range of infections. Common side effects are nausea, vomiting, peripheral neuropathy, dysglycemia, and arrhythmias, with more serious collagen-disruption-associated complications including tendon rupture and retinal detachment.
The association of increased aortic dissection has been highlighted in various studies and safety communications from health authorities. For example, the FDA issued a warning in December 2018 about the potential risks of aortic aneurysm and dissection with fluoroquinolone use.2
Fluoroquinolones may increase the risk of aortic dissection by damaging the collagen and connective tissue in the aortic wall. Fluoroquinolones can damage these components by stimulating matrix metalloproteinases (MMPs), which are gelatinases that have collagenolytic activity.
Beta-blockers, on the other hand, are protective against aortic dissection. They are routinely used in Marfan patients because they reduce the rate of aortic root dilation by decreasing heart rate and aortic wall stress.3
Loop diuretics are not linked to an increased risk of aortic aneurysm or dissection. They are used for intravascular volume management in patients with hypertension or heart failure but do not play a direct role in aortic pathology in Marfan syndrome.
Given the concern for aortic aneurysm and aortic dissection, some institutions prefer not to use fluoroquinolones in high-risk patients unless no other treatment options are available.
REFERENCES
1. Zalzstein, Eli & Hamilton, Robert & Zucker, Nili & Diamant, Samuel & Webb, Gary. (2003). Aortic dissection in children and young adults: Diagnosis, patients at risk, and outcomes. Cardiology in the young. 13. 341-4. 10.1017/S1047951103000696.
2. FDA In Brief: FDA warns that fluoroquinolone antibiotics can cause aortic aneurysm in certain patients. 2018. Available at: https://www.fda.gov/news-events/fda-brief/fda-brief-fda-warns-fluoroquinolone-antibiotics-can-cause-aortic-aneurysm-certain-patients.
3. Zhang, Jiawei MDa; Zhang, Zhe MBb,∗. Fluoroquinolones increase the risk of aortic aneurysm and dissection: A protocol for meta-analysis.Medicine 100(51):p e28081, December 23, 2021. | DOI: 10.1097/MD.0000000000028081
