Updated Black-box Warnings for Fluoroquinolones

In July, 2016, the FDA made significant changes to the warning labels for all fluoroquinolone antibiotics (Cipro/ciprofloxacin, Levaquin/levofloxacin, Avelox/moxifloxacin, Floxin/ofloxacin, Noroxin/norfloxacin, and Factive/gemifloxacin). These label changes include black-box warnings for fluoroquinolones that state:


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

You can view all of the updated fluoroquinolone labels HERE.

These updated black-box warning labels are HUGE steps in the right direction. The FDA is acknowledging, in a highlighted black-box section of the warning labels, that fluoroquinolone adverse-effects can be serious, irreversible, and disabling. They’re also acknowledging peripheral neuropathy and central nervous system effects, in addition to the adverse-effects on tendons, in the black-box warning. Additionally, the black-box warning states explicitly that fluoroquinolones should not be used for treatment of patients with chronic bronchitis, uncomplicated cystitis (I wish they would have said “urinary tract infections” instead of “cystitis” as they did in the hearings and preliminary documentation), and sinusitis, unless there are no alternative treatment options.

If this updated black-box warning had been in place when fluoroquinolones were first introduced to the market (in the 1980s and 1990s), many people would have been saved from being “floxed.” If these warnings had been in place when fluoroquinolones entered the market, or even when people started screaming about the significant damages and injuries caused by fluoroquinolones, perhaps more doctors would be aware of the dangers of these drugs, and they would be used more appropriately (only in life-or-death situations where there are no alternatives available). Currently, unfortunately, most people are not aware of the devastating effects of fluoroquinolones. Hopefully this updated black-box warning label will enlighten both patients and physicians about the serious and severe dangers of fluoroquinolones.

Prior to this update, the black-box warning for Cipro (and other fluoroquinolones) stated:

Fluoroquinolones, including CIPRO®, are associated with an increased risk of tendinitis and tendon rupture in all ages. This risk is further increased in older patients usually over 60 years of age, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants (see WARNINGS).

Fluoroquinolones, including CIPRO, may exacerbate muscle weakness in persons with myasthenia gravis. Avoid CIPRO in patients with known history of myasthenia gravis (see WARNINGS).

This 2008 black-box warning was hard fought for, as both Bayer and Ortho-McNeil-Janssen (a subsidiary of Johnson & Johnson) wanted to bury the risks of tendon ruptures in small-text embedded in the warning labels, rather than highlighting the increased risk in a black-box warning. It was only after Public Citizen sued the FDA that this black-box warning was added to fluoroquinolone warning labels.

Though the old black-box warning was a significant victory at the time, it left much to be desired. The statement that, “This risk is further increased in older patients usually over 60 years of age, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants,” suggests that those who are under 60 years of age, not taking corticosteroid drugs, and who have not had kidney, heart, or lung transplants, can safely take fluoroquinolones. Though it is also noted that the risk of tendon ruptures is increased for people of “all ages,” it is common to hear of people being told that they wouldn’t have problems with fluoroquinolones because only older people, or people with myasthenia gravis, are at risk for experiencing adverse-effects. This simply isn’t true, as there are thousands of people who have been hurt by fluoroquinolones who are under the age of 60, do not have myasthenia gravis, who are not on corticosteroid drugs, and who have not had an organ transplant.

The old black-box warning gave people (both patients and physicians alike) the impression that fluoroquinolones are only unsafe for certain, small sections of the population. The truth is, fluoroquinolones can cause devastating, severe, disabling adverse-reactions in people who are young and old, strong and weak, fit and out-of-shape, and, at this time, there is no way to determine who will have an adverse-reaction and who won’t. There are almost certainly factors that predispose some people toward having devastating adverse-reactions to fluoroquinolones while others seem to be able to take fluoroquinolones without problem, but we don’t know what those predispositions are. No one knows if people who have latent autoimmune or endocrine system disorders, or who have MTHFR genetic mutations, or who are G6PD deficient, or who have leaky gut, or who have been exposed to heavy metals, or any other potential risk factor, are more succeptible to fluoroquinolone adverse-reactions than anyone else. There is a dice-roll, a pull of the Russian roulette trigger, every time ANYONE takes a fluoroquinolone because NO ONE knows what the real risk factors are, or even how frequent/rare adverse-reactions are. I wish that it was explicitly said on the fluoroquinolone warning labels, preferably in the black-box warning, that risk-factors are currently unknown and that everyone who takes fluoroquinolones is potentially at risk for experiencing disabling adverse-effects.

I also wish that it was noted in the black-box warning that adverse reactions to fluoroquinolones can be delayed for weeks, months, or even years after administration of the drugs has ceased. And I wish that people were warned that ceasing administration of the drug may not stop the adverse-reaction, and that the symptoms of fluoroquinolone toxicity can continue long after the drug “should” be out of one’s system.

I also wish that the danger of co-administering fluoroquinolones and corticosteroid drugs had stayed in the black-box warning, and I wish that the contraindication of NSAIDs and fluoroquinolones was noted in the black-box warning.

I wish that “cystitis” was changed to “urinary tract infection,” or that they were both mentioned as ailments for which the use of fluoroquinolones is not appropriate unless there is no alternative. I also wish that prostatitis and travelers’ diarrhea were added to the list of ailments for which fluoroquinolones should not be used unless there is no alternative.

Perhaps the next iteration of the black-box warning on fluoroquinolones will note those things. I wish I, and my doctor, had been warned more thoroughly about the dangers of fluoroquinolones before she prescribed them to me, and before I took them. Hopefully the updated black-box warning label will help physicians and patients to realize how dangerous fluoroquinolones are, and will keep many people from getting “floxed.”

Though the updated black-box warnings still leave a bit to be desired, they are a HUGE step in the right direction. Acknowledgement from the FDA that fluoroquinolone adverse-effects can be irreversible and disabling, and that they should not be used to treat many common conditions unless there are no other treatment options available, is very big news, and it should be celebrated. We are making progress, and hopefully fewer people will be hurt by fluoroquinolones because of these black-box warning updates.



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12 thoughts on “Updated Black-box Warnings for Fluoroquinolones

  1. FloxFromCipropol August 19, 2016 at 1:58 pm Reply

    Huge step forward. Battle is won.
    We must win a war -> life or dead situations fq prescription only.
    Thanks for this!

  2. girardia August 20, 2016 at 4:39 am Reply

    Great summary of what is and what is not in the new black box warning. I remember when I first heard of black box warnings and figured it meant that the most dangerous drugs arrive in black packaging to alert the pharmacists to be careful but alas, it’s only a little black line around a warning in the product literature for the doctors and pharmacists and not even something the patient sees unless he or she goes looking for the information. This was a HUGE step in the right direction, but it was just one more step on a journey of many miles. We will not stopp until there are giant wings of medical centers dedicated to taking care of us and researching how to determine who might be harmed and why. We need giant government agencies working on ways to make our lives less unpleasant. We need ICD numbers and we need every doctor in the world to be well aware of fluoroquinolone toxicity and the best practices for treating us, and so on and so forth. This will take at least another 20 years before we get all that we deserve, and speaking of getting what we deserve, the people who did this to us, on purpose, should also get what they deserve, like life in prison or better yet, execution. The executives of these companies, past and present, should all die behind bars for these massive ongoing crimes against humanity. In the meantime we will celebrate this small victory and then double down on our efforts. Thanks Lisa for all your hard work towards the cause! Mark Girard

    • Lisa August 20, 2016 at 6:56 am Reply

      Great points, Mark! This certainly isn’t a stopping point. We have made progress though, and I’m glad to see that we’re moving in the right direction.

  3. Wendy Graham August 20, 2016 at 9:03 am Reply

    Thank you for helping so many people. My son was given levaquin last Spring and is suffering terribly. His insurance will not cover any treatment as there is no code for this diagnosis. Have any lawsuits been successful in getting help for people who are too late for this new warning system? Is the FDA going to take responsibility for the thousands of innocent people they have injured ? What can I do to help? If anyone has any guidance or advice, it would be greatly appreciated! Thank you again Lisa!!

  4. Barbara Arnold August 20, 2016 at 10:26 pm Reply

    Hi Lisa,
    This latest warning is a huge step.
    I am printing copies and putting them in large envelopes and taking them to my local hospital addressed to the Rheumatologists that I have seen and been told there is nothing wrong with me, that I “may have a nerve disease” that would not give me IV’s of glutathione as it’s “not on their list”. The same Rheumatologist’s that DIAGNOSED me with side effects of cipro and told me it’s RARE grrrrrrr even though I explained the symptoms are vast and varied and may not show up for MONTHS LATER. The same Rheumatologist that when I informed her that there was a black box warning in America her arrogant ignorant reply was “this is Spain not America”
    I hate them and their lazy ignorance. Their lack of care and compassion. Their inability to take responsibility and research this subject. Their sneering looks when you have more knowledge than them because you have a vested interest. What do I know I’m a 73 year old woman who’s not worth bothering about. They think I will just go away and die. How they underestimate me.
    My last visit to them last week was to try and get IV’s of glutathione, as it’s really expensive privately. I more or less knew I was wasting my time, but I was appalled to hear her say that flouroquinolones were a very popular group of antibioctics that they use all the time. This AFTER I told her that the symptoms are varied and vast and may not show up for weeks or months later. THEY ARE NEGLIGENT IN THEIR DUTY OF CARE. I wish I could sue EVERY ONE OF THEM.
    I urge ALL floxies to do the same, to kick up as much fuss as possible, to take the printed ammunition with you as EVIDENCE .
    Every little step we all take towards getting this information “out there” eventually has an impact. Dont give up or get complacent. Think of a baby learning to walk, how many times does he fall down before he eventually stands up and walks.
    I love all you brave floxies and hope with all my heart we will all get through this and recover.
    Lisa is THE SHINING STAR who gave us all this amazing information, she has tirelessly continued the fight even though she has recovered. THANKYOU THANKYOU THANKYOU LISA.
    HUGS Barbara

  5. Thomas R. Sharkey September 4, 2016 at 8:20 pm Reply

    I like posts like yours, it make me rethink more about this world. please keep updating. http://www.cd-bioparticles.com/l/Active-Magnetic-Particles_20_193_0.html

  6. Richard June 28, 2017 at 11:32 pm Reply

    Yesterday my doctor prescribed levofloxacin for acute bronchitis I’ve had for about a month. Before taking it I read the package insert and did some Internet research (including finding this website). I decided not to take the drug. Thank you for sharing this information and helping me make an informed decision. When I see my doctor for followup, I will ask for a different antibiotic, and I will explain the reason.

    • Barbara Arnold June 29, 2017 at 5:45 am Reply

      Hi Richard, phew really glad you had the nounce to read the insert and did not take this crap. Thats what did it for me, my Doctor gave me Cipro for bronchitis and the bomb went off. I have had it since and taken amoxcillin, it seems pretty beneign and it cleared up my bronchitis. Good luck for your future, you probably had a lucky escape.

      • Richard June 30, 2017 at 4:00 am Reply

             At the very least I escaped months and months of worrying.  I tend to worry a lot about what *might* happen.  And even if the levofloxacin did not cause any adverse reactions in me, I would still have worried myself to death that it eventually would.
             What I find really disturbing is the fact that, even though this drug has a black box warning, neither my doctor not the pharmacy said a single word to me about it.  The doctor just told me that it was the best antibiotic for my condition.  And the pharmacist said nothing at all.  (And they both know that I am over 60 years old, which puts me at greater risk.)  I wish there were a law requiring doctors and pharmacies to warn patients when a drug carries such warnings.  But of course there is not.  That’s why websites like this one are so important.  They give patients the information they need to make a truly informed decision.  But of course most patients don’t even bother reading the monograph from the pharmacy, let alone ask for and read the package insert.  Fortunately I’m one of those who do.  My thanks again to you and to everyone who shared their information about this drug.  It was very helpful to me in making my decision not to take it.

  7. Tikvah Duesterbeck August 17, 2017 at 12:42 pm Reply

    the link isn’t working for the FDA

  8. Elizabeth Dallas Voss May 7, 2018 at 1:56 pm Reply

    Unfortunately the “new warning label of 2016” didn’t keep me from getting floxed in June 2017! I wasn’t “warned” by my doctor, pharmacist or even the label on the bottle…more has got to be done!

  9. lyndamae ooms June 26, 2019 at 7:06 am Reply

    is there a protocol to follow to get this stuff out of my body… i have taken both cipro twice and levo once that i remember. i believe i have connective tissue issues… i am detoxing daily with chlorella… i also take cilantro drops… eat a healthy diet mostly plant based.

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