Fluoroquinolone antibiotics tendonitis relation best

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The first reports of an association between fluoroquinolone antibiotics and tendonitis came from New Zealand and France in 1992.

There have been many since.

A prospective ultrasound study was conducted at the Hospital Universitaire Dupuytren. Some 23 subjects (15 female) were given a fluoroquinolone orally for two weeks. All had normal Achilles tendons at day 0. By day seven, 14 (61 per cent) had echographic tendonitis. Both sides were affected in seven, and two (7 per cent) were symptomatic.

The ultrasound features were of hypoechogenicity (50 per cent), peri-tendous effusion (28 per cent) and tendon thickening (22 per cent). For a volunteer study in healthy controls, no ruptures occurred.

The mechanism by which fluoro-quinolone antibiotics cause this problem is not clear. In animal studies, they can cause arthritis. Care should be taken when prescribing for those on steroids. If tendon pain develops, the antibiotic should be stopped and the patient advised to rest the affected area and avoid exercise. Diagnostic ultrasound is the most convenient and cheapest way to prove the diagnosis. MRI is more definitive.

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In clinical practice now, it is not uncommon to find patients who have been exposed to fluoroqunilone antibiotics and have tendon issues, including rupture. The most devastating of these tendon ruptures occur in the Achilles tendon.

The following are references to this problem:

1. The Annals of Pharmacotherapy: Vol. 33, No. 7, pp. 792-795. DOI 10.1345/aph.18298© 1999 Harvey Whitney Books Company.

Levofloxacin-induced bilateral Achilles tendonitis

Lewis JR, JG Gums, and DL Dickensheets

OBJECTIVE: To report a case of possible levofloxacin-induced bilateral Achilles tendonitis. CASE SUMMARY: An 83-year-old white woman presented to her physician with five days of hemoptysis. She was diagnosed with right lower-lobe pneumonia based on chest X-ray, and levofloxacin 500 mg/d po for 10 days was prescribed. Three days into treatment she began having a variety of adverse effects, including severe nausea, constipation, stomach cramps, and dizziness. Signs of tendonitis began three days after treatment and peaked four days after completion of therapy. Two weeks later, she was treated by her podiatrist with an ankle immobilizer and rest. At her three-week follow-up, she had marked improvement in her pain and bruising; however, her symptoms had not completely resolved. DISCUSSION: Tendonitis and tendon rupture are rare adverse effects of fluoroquinolone antibiotics; there are no reports in the literature of levofloxacin-induced tendonitis. As newer fluoroquinolones become available, the postmarketing studies will become increasingly important to capture the data on rare but serious adverse effects not discovered in the premarketing trials. CONCLUSIONS: To our knowledge, this is the first reported case of tendonitis caused by levofloxacin reported in the literature. Reports have been made, however, to the manufacturer via postmarketing surveillance. As more people are treated with newer fluoroquinolones, the clinical incidence of tendon rupture with these agents may become clearer.

2. Food and Drug Administration. (1996). Reports of Adverse Events with Fluoroquinolones.

3. Bailey, R., Kirk, J., & Peddie, B. (1983). Norfloxacin-induced rheumatic disease (Letter). New Zealand Medical Journal, 96, 590.

4. Borderie, P., Marcelli, C., Herisson, C., Simon, L. (1993). Spontaneous rotator cuff tear during fluoroquinolone antibiotics treatment: A case report of two cases (abstr). Arthritis and Rheumatology, (suppl 9)36, 163.

5. Gillet, P., Blum, A., et al. (1993). Fluoroquinolone-associated Achilles tendonitis: MRI findings (abstr). Arthritis and Rheumatology, (suppl 9)36, 163.

6. Harrell, R. (1999). Fluoroquinolone-induced tendinopathy: What do we know? South Med Journal, 92, 622-625.

7. Hayem, G., Thuong-Guyot, M., et al. (1993). Fluoroquinolone-associated Achilles tendonitis: MRI findings (abstr). Arthritis and Rheumatology, (suppl 9)36, 163.

8. Huston, K. (1994). Achilles tendonitis and tendon rupture due to fluoroquinolone antibiotics [Letter]. New England Journal of Medicine, 331, 748.

9. Kashida, K., & Kato, M. (1997). Characterization of fluoroquinolone-induced Achilles tendon toxicity in rats: Comparison of toxicities of ten fluoroquinolones and effects of anti-inflammatory compounds. Antimicrob Agents Chemotherapy, 41, 2389-2393.

10. Kato, M., Takada, Y., Kashida, Y., Nomura, M. (1995). Histological examination on Achilles tendon lesions induced by quinolone antibacterial agents in juvenile rats. Toxicol Patol, 23, 385-392.

11. Koeger, A-C., Chaibi, P., Roger, B., et al. (1993). Tendon complications during treatment with fluoroquinolones evaluated by MR imaging (abstr). Arthritis and Rheumatology, (suppl 9)36:139.

12. Le Huec, J., Schaeverbeke, T., & Chauveaux, D., et al. (1995). Epicondylitis after treatment with fluoroquinolone antibiotics. Journal of Bone and Joint Surgery Br, 77, 293-295.

13. Lee, W., & Collins, J. (1992). Ciprofloxacin associated bilateral Achilles tendon rupture. Austrailia and New Zealand Journal of Medicine, 22, 500.

14. Martens, M., Wouters, P., Burssens, A., & Mulier, J. (1982). Patellar tendonitis: Pathology and results of treatment. Acta Orthop Scand, 53, 445-450.

15. McEwan, S., & Davey, P. (1988). Ciprofloxacin and tenosynovitis. Lancet, 15, 900.

16. McGarvey, W., Singh, D., & Trevino, S. (1996). Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: A case report and literature review. Foot Ankle Int, 17, 496-498.

17. Mont, M., Mathur, S., Frondoza, C., & Hungerford, D. (1996). The effects of ciprofloxacin on human chondrocytes in cell culture. Infection, 24, 151-155.

18. Movin, T., Gad, A., & Guntner, P., et al. (1997). Pathology of the Achilles tendon in association with ciprofloxacin. Foot Ankle Int, 18, 297-299.

19. Movin, T., Gad, A., Reinholt, F., & Rolf, C. (1997). Tendon pathology in long-standing achillodynia: Biopsy findings in 40 patients. Acta Orthop Scandinavia, 68(2), 170-175.

20. Norkin, M., & Frankel, V., (2001). Basic Biomechanics of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott Williams & Wilkins.

21. Pierfitte, C., Gillet, P., & Royer, R. (1995). More on fluoroquinolone antibiotics and tendon rupture [Letter]. New England Journal of Medicine, 332, 193.

22. Price, A., Evanski, P., & Waugh, T. (1986). Bilateral simultaneous Achilles tendon ruptures: A case report and review of the literature. Clinical Orthopaedics, 213, 249-250.

23. Ribard, P., Audisio, F., et al. (1992). Seven Achilles tendonitis including three complicated by rupture during fluoroquinolone therapy. Journal of Rheumatology, 19, 1479-1481.

24. Rosentiel, N., & Dieter, A. (1994). Quinolone antibacterials: An update of their pharmacology and therapeutic use. Drugs, 47(6), 873-900.

25. Royer, R., Peirfitte, C., & Netter, P. (1994). Features of common tendon disorders with fluoroquinolones. Therapie, 49, 75-76.

26. Szarfman, A., Chen, M., & Blum, M. (1995). More on fluoroquinolone antibiotics and tendon rupture [Letter]. New England Journal of Medicine, 332, 193.

27. Ward, J., & Greene, M. (2001). Fluoroquinolones and tendinopathy: A case study with implications for physical therapy. Physical Therapy: Orthopedic Practice, 13, 12-13.

28. Williams III, R., Attia, E., Wickiewicz, T., & Hannafin, J. (2000). The effect of ciprofloxacin on tendon, paratenon, and capsular fibroblast metabolism. American Journal of Sports Medicine, 28, 364-369.

29. Zabraniecki, L., Negrier, I., & Vergne, P., et al. (1996). Fluoroquinolone induced tendinopathy: Report of six cases. Journal of Rheumatology, 23, 516-520.

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