[Novel side effects of moxifloxacin: making a balanced decision again]

Earlier this year, a 'Dear Doctor' letter was sent to Dutch health care professionals, describing the rare occurrence of fulminant hepatitis and the Stevens-Johnson syndrome or toxic epidermal necrolysis in patients using moxifloxacin. This resulted in media attention, questions in parliament and moxifloxacin being banned from the formulary in several hospitals. Was this reaction justified? In the Netherlands, moxifloxacin is only mentioned in the practice guideline on the treatment of severe community-acquired pneumonia. Alternatives for moxifloxacin for this indication are penicillin combined with ciprofloxacin, or cephalosporins in combination with erythromycin. The associated risks, in particular fatal anaphylaxis and sudden cardiac death, of these combinations are substantially higher compared to the reported incidence of severe moxifloxacin-associated liver and skin toxicity. 'Dear Doctor' letters are important when new side effects become apparent, but these side effects must be placed in the overall balance of pros and cons of a drug as compared to the alternatives.