As a class, quinolone antibiotics have been rarely associated with hypoglycemia in non-diabetic patients and rare reversible episodes of hypoglycemia documented in the literature typically occur within the duration of action of the medication. In this case, however, we believe the effect of the medication persisted much longer

Ball, Emily

Khashaei, Sepehr

Raschke, Jeremy

English

University of New Mexico

University of New Mexico
UNM Digital Repository
Undergraduate Medical Student Research Health Sciences Center Student Scholarship
2016
Moxifloxacin: A Unique Cause of Severe
Hypoglycemia
Emily Ball
Sepehr Khashaei
Jeremy Raschke
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Recommended Citation
Ball, Emily; Sepehr Khashaei; and Jeremy Raschke. "Moxifloxacin: A Unique Cause of Severe Hypoglycemia." (2016).
https://digitalrepository.unm.edu/ume-research-papers/2
Moxifloxacin: A Unique Cause of Severe Hypoglycemia 
Emily Ball, MPH, MSIII, University of New Mexico School of Medicine, Albuquerque, New Mexico  
Sepehr Khashaei, MD, New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico 
Jeremy Raschke, PharmD, BCPS, New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico 
Case Description:  
A thin 61-year-old man with a past medical history significant for 
schizoaffective disorder, bipolar disorder and recent episode of 
community acquired pneumonia (CAP) presented with shaking and 
confusion after having fallen while under observation as an inpatient 
psychiatric patient. A random blood glucose measurement taken at the 
time of the fall was found to be 26 mg/dL. The hypoglycemia and 
symptoms were rapidly reversed with oral glucose tablets, however, the 
patient continued to suffer from recurrent hypoglycemia requiring 
intervention with intravenous dextrose and oral glucose until hospital 
day 4 when his blood glucose stabilized within the normal range. The 
patient's A1c, insulin, insulin Ab, proinsulin, c-peptide, TSH, 
sulfonylurea level and cosyntropin stimulation tests were all within 
normal limits.  The patient was recently treated for CAP with 
moxifloxacin 400 mg PO daily for 7 days and received his last dose of 
the medication 4 days prior to presentation.  He had no other recent 
changes in medications.    
Discussion:  
Upon presentation, the origin of the patient's hypoglycemia was 
unclear.  He had no significant medical comorbidities, his psychiatric 
illness had been stable on the same treatment regimen for many years, 
and he was in an inpatient ward with a very low likelihood of having 
been given insulin or any other hypoglycemic agent.  Omeprazole was 
the only other medication the patient was receiving associated with 
hypoglycemia and was discontinued on admission to the medical ward.  
This was thought not to be the cause of his acute hypoglycemia as he 
had been taking omeprazole for many years. Fluoroquinolones as a 
class have been shown to cause hypoglycemia by inappropriate 
activation of pancreatic beta cells resulting in increased insulin 
release.1  Considering the patient's recent course of moxifloxacin this 
was thought to be the most likely culprit.  Pharmacy and endocrinology 
services were consulted and both agreed that this was the most likely 
explanation for the patient’s presenting symptoms.   
Among diabetic patients, especially those taking sulfonylureas, 
dysglycemia is a well-established side effect of fluoroquinolone 
antibiotics with moxifloxacin being most likely to cause hypoglycemia 
in these patients.2-5  Rarely fluoroquinolones have been shown to cause 
persistent hypoglycemia in non-diabetic patients.1,6&7  A handful of case 
reports have been published showing an association between 
levofloxacin and hypoglycemia.1,6&8  A phase IV study of 1701 patients 
treated with levofloxacin for CAP found only 2 suffered an adverse 
hypoglycemic event.8 moxifloxacin is much less commonly cited as a 
cause of hypoglycemia among non-diabetic patients.7-8 Additionally, a 
perplexing aspect of this case was the duration of time from 
discontinuation of the offending medication to appearance of severe, 
symptomatic hypoglycemia.  The patient reported decreased oral 
intake the morning preceding presentation, which may have worsened 
any persistent underlying hypoglycemia and resulted in altered mental 
status and fall.  Advanced age and reduced renal function are thought 
to be risk factors for the development of hypoglycemia among non-
diabetic patients treated with fluoroquinolones.  This case adds to the 
base of literature regarding severe hypoglycemia resulting from 
moxifloxacin administration and brings awareness to the rare, but 
potentially fatal side effect of this commonly used class of medications.  
References:  
1. Wang, S. & Rizvi, A. A. Levofloxacin-induced hypoglycemia in a nondiabetic patient. Am. J. Med. Sci. 331, 334–335 (2006). 
2. Chou, H.-W. et al. Risk of severe dysglycemia among diabetic patients receiving levofloxacin, ciprofloxacin, or moxifloxacin in 
Taiwan. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 57, 971–980 (2013). 
3. Parekh, T. M. et al. Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas. JAMA Intern. 
Med. 174, 1605–1612 (2014). 
4. Singal, D. K., Mittal, A. & Prakash, A. Recurrent episodes of hypoglycemia induced by moxifloxacin. Indian J. Pharmacol. 45, 
301–302 (2013). 
5. Micheli, L., Sbrilli, M. & Nencini, C. Severe hypoglycemia associated with levofloxacin in Type 2 diabetic patients receiving 
polytherapy: two case reports. Int. J. Clin. Pharmacol. Ther. 50, 302–306 (2012). 
6. Fusco, S. et al. Severe hypoglycemia associated with levofloxacin in a healthy older woman. J. Am. Geriatr. Soc. 61, 1637–
1638 (2013). 
7. Kapoor, R. et al. Life-threatening hypoglycemia with moxifloxacin in a dialysis patient. J. Clin. Pharmacol. 52, 269–271 (2012). 
8.  Mandavia, D. R., Virpariya, M. M., Patel, T. K. & Tripathi, C. B. Moxifloxacin-induced hypoglycemia in a non-diabetic patient. 
Curr. Drug Saf. 7, 183–185 (2012). 
Medications:  
Acetaminophen 500 mg PO PRN   
Clonazepam 0.5 mg PO daily  
Clozapine 400 mg PO daily    
Docusate/Senna 50/8.6 mg PRN  
Finasteride 5 mg PO daily    
Gabapentin 1200 mg PO TID 
Lithium 600 mg PO BID    
Omeprazole 20 mg PO daily  
Tamsulosin 0.8 mg PO daily    
Trazodone 200 mg PO daily  
Introduction: 
As a class, quinolone antibiotics have been rarely associated with 
hypoglycemia in non-diabetic patients and rare reversible episodes of 
hypoglycemia documented in the literature typically occur within the 
duration of action of the medication. In this case, however, we believe 
the effect of the medication persisted much longer.  
Proposed Mechanism of Fluoroquinolone-Induced 
Hypoglycemia:  
Like sulfonylureas, the medications disrupt the function of the ATP-
sensitive K+ channel, resulting in increased insulin release by 
pancreatic beta cells.  
Hypoglycemia Workup 
Whipple’s Triad Present? 
1. 
Observed 72 hour fast 
NO, but clinical  
        suspicion is high  
 YES 
       Symptoms + low blood glucose +  
relief of symptoms with increased blood glucose 
Only Postprandial Hypoglycemia 
Mixed Meal Test YES 
NO 
2. 
Order the Following as Indicated by Clinical Scenario: 
• Insulin  
• Proinsulin 
• Insulin Antibody  
• Beta-hydroxybutyrate  
• C-peptide  
• Sulfonylurea & Meglitinide Level 
Results of these studies will help  
Differentiate between factitious  
hypoglycemia, autoimmune  
hypoglycemia, insulinoma and other  
etiologies 
Comment:  
Also consider checking TSH & cosyntropin stimulation test to rule 
out hypoglycemia resulting from hypothyroidism and adrenal  
insufficiency 
3. 
0
20
40
60
80
100
120
140
160
Day 1 Day 2 Day 3 
Blood Glucose Measurements 
Day 3 
Patient on D5W  
Infusion 100 mL/hr        
6 a.m. 
4 a.m. 
6 a.m. 
D5W stopped 
before Lunch 
D5W re-started 
D5W stopped 
before Lunch 
oral glucose and food 
were given 
Remaining Inpatient Days 
Without Hypoglycemic 
Episodes (Total stay 7 days) 
Day 4 
Patient on D5W  
Infusion 100 mL/hr        
4 a.m.         
6 a.m.         
Blood Glucose Measurements 
Remaining Inpatient Days 
Without Hypoglycemic 
Episodes (Total stay 7 days) 
D5W  
stopped 
before 
lunch         
D5W 
re-started 
D5W  
stopped 
6 a.m.         
before lunch         
oral glucose 
& food given 
Day 1 Day 2 Day 3 


Moxifloxacin: A Unique Cause of Severe Hypoglycemia

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Moxifloxacin: A Unique Cause of Severe Hypoglycemia

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