Fluoroquinolones and tendons

[Guest ral]

Real life numbers?  So tired of the all the exclamation points and red flags when I go to order Levaquin.

All docs I work with are seriously unconcerned about it.  Anyone here ever have a case of rupture in a patient.  I typically advise against strenuous or vigorous activity while taking but, that’s about it. 

[GetMeOuttaThisMess]

Real life numbers?  So tired of the all the exclamation points and red flags when I go to order Levaquin.
All docs I work with are seriously unconcerned about it.  Anyone here ever have a case of rupture in a patient.  I typically advise against strenuous or vigorous activity while taking but, that’s about it. 

Yep, one that ortho blamed it on (years ago). I tell them the same that you do, and even called one back yesterday after I decided to change rx before sending. Yesterday’s was three weeks of fever (103 in office)and cough. LLL pneumonia on exam. Didn’t want a work release.


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[Cideous]

I have written literally thousands of quinolone scripts.  Never seen it one time.  Not once.

[sas5814]

I had a colleague in my office get a diffuse painful myalgia and tendonitis or algia or opathy depending on how you look at it. It lasted several months.

I had one patient develop tendon pain but I think she talked herself into that after reading all the warnings.

I wrote thousands of quinolone scipts before all this started and never heard about any big problems.

That said...anecdotes aren't science.

[camoman1234]

2 minutes ago, sas5814 said:

I had a colleague in my office get a diffuse painful myalgia and tendonitis or algia or opathy depending on how you look at it. It lasted several months.

I had one patient develop tendon pain but I think she talked herself into that after reading all the warnings.

I wrote thousands of quinolone scipts before all this started and never heard about any big problems.

That said...anecdotes aren't science.

But are they? I think a patient account is somewhat science as science changes all the time and even though the patient wasn't in a "setting" does not mean their positives or negatives is not true/science. I would not take that patients experience as full proof, but would have it in the back of my mind as years of HCE you gain "knowledge" based off your experiences. 

[sas5814]

What we learn is experience....or the other way around but you know what I mean.

I agree with what you are saying basically but there is risk, to you and perhaps your patients, if you substitute your experience for what is considered general knowledge or the current state of knowledge and data. Write 10k Levaquin scripts and get sued for the 1 achilles tendon rupture. You will lose because the other side will be able to produce reams of reports and studies and expert opinions that will say you were swimming against the stream. All the experts in the world are unlikely to change anyone's mind with their opinions to the contrary based on experience.

[Guest ral]

One case of anything can hurt you, if it's in the literature.  That said, where do you stop prescribing?

Commonly held associations such as c-diff colitis with a large number of antibiotics, gastric ulcers with NSAIDs,  ototoxics, nephrotoxics, hepatotoxics, rashes, nausea, headaches, myalgias...anything resulting in loose correlation with any medication can burn you.

[sas5814]

Indeed. It is always a question of balance and I tell every patient there is no such thing as a free drug. They all have risks, hazards, side effects, and drug drug interactions. I used to have a handout about what cancer risks were increased with taking what vitamin supplement. I have lost it but it made a great point about meds and risks.

The one-time tendon rupture would be a review of other meds that were available and "safer". Let me promise you getting your entire professional life picked to shreds in a malpractice case isn't fun...it also doesn't have a lot to do with what is true and what isn't. It has to do with emotion.

[Reality Check 2]

I had a gentleman rupture both rotator cuffs after a course of Cipro. His cuffs were already elderly and likely hanging on by threads but they both ruptured as he stood up from his recliner.

I think the bigger point is DO NOT USE these drugs unless all other categories have failed or aren't indicated by culture. We no longer use Cipro for firstline female UTIs and start good therapy and await cultures before getting out the Gatling Gun. Pyelonephritis is another story.

We use too many abx already and we are encouraging more super bugs. Sinuses don't need Cipro or Levaquin until the CT is positive and nothing else works and they are long term patients with chronic disease.

Diverticulitis is tough - Flagyl and Cipro have always been the recipe. I see GIs around me doing Flagyl alone at first unless febrile and awaiting admit or with an abscess.

So, warnings are there - I am exhausted by our EMR telling me the patient had a diflucan 2 years ago and I should consider that when rx'ing something new.

Common Sense - unfortunately not all that common and in need of a good reboot.......

just my crusty old 2 cents

[Guest ral]

My favorite of the “lesser of two evils” decision lately, has been older gentlemen with prosatitis.  Review of med hx and labs frequently reveals they are on an ACEI, and last three potassium levels have been right around 5.

Bactrim warns me of lethal potassium levels, and Cipro or Levaquin says they will be crippled when their achilles all snap.

Funny how none of this crap was a consideration until the lawyers got involved.  

 

[plant biologist]

I'll be the pilot here. I saw two cases of tendon rupture in sedentary patients my first year of practice (I didn't prescribe the levaquin initially). I haven't seen a single case since then.

On a side note, I've seen rhabdo multiple times in CrossFit participants but never in someone taking a stating.

[plant biologist]

Oops, I didn't proofread. Substitute outlier for pilot and statin for stating. Stupid autocorrect.

[cbrsmurf]

From UptoDate:

 

"In a database study of 6.4 million patients, 28,907 cases of Achilles tendinopathy and 7685 cases of tendon rupture were identified [117]. Use of a fluoroquinolone was strongly associated with Achilles tendinopathy (odds ratio [OR] 4.3, 95% CI 3.2-5.7) and tendon rupture (OR 2.0, 95% CI 1.2-3.3). The association with Achilles tendinopathy was stronger among individuals who were >60 years old (OR 8.3 versus 1.6), nonobese (OR 7.7 versus 2.4), and those using oral glucocorticoids (OR 9.1 versus 3.2). Female sex was significantly associated with tendon rupture (OR 4.0 versus 1.1).

Kidney, heart, and lung transplantation have been identified as additional risk factors [116]. The median duration of fluoroquinolone use before the onset of tendon injury is eight days [115]. The risk of tendinopathy may be exposure related; doses should be adjusted based on renal function to avoid possible drug accumulation [118]."

 

111

|  PubMed

TI

Fluoroquinolone induced tendinopathy: report of 6 cases.

AU

Zabraniecki L, Negrier I, Vergne P, Arnaud M, Bonnet C, Bertin P, Treves R 

SO

J Rheumatol. 1996;23(3):516. 

 

We describe 6 cases of fluoroquinolone induced Achilles tendinitis in 4 women and 2 men, mean age 68.6 years. Patients presented with pain and swelling of sudden onset, which was most often bilateral. Tendon rupture was frequent, accompanied by nodules and ecchymoses. The diagnosis was clinical, occasionally ultrasonography was helpful; the role of magnetic resonance imaging has yet to be defined. Certain risk factors were found, particularly association with longterm steroid therapy, and close surveillance of high risk subjects is mandatory. Although proper dosage and duration of treatment were respected, the principal fluoroquinolones were clearly incriminated. We found no correlation between treatment duration and the degree of involvement. Nevertheless, immediate discontinuation of the antibiotic and placement of both Achilles tendons at rest is essential. Early and appropriate management did not prevent prolonged recovery times and there was always a risk of functional sequelae. This side effect is class related and rare. Its physiopathologic mechanism is poorly understood.

AD

CHRU Dupuytren, Department of Rheumatology, Limoges, France. 

PMID

8832995

112

|  PubMed

TI

Fluoroquinolones and risk of Achilles tendon disorders: case-control study.

AU

van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH 

SO

BMJ. 2002;324(7349):1306. 

AD

Department of Epidemiology&Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands. 

PMID

12039823

113

|  PubMed

TI

Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids.

AU

van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HM, Rowlands S, Stricker BH 

SO

Arch Intern Med. 2003;163(15):1801. 

 

BACKGROUND In several case reports, the occurrence of Achilles tendon rupture has been attributed to the use of quinolones, but the epidemiologic evidence for this association is scanty.

 

METHODS We conducted a population-based case-control study in the General Practice Research Database in the United Kingdom during the period 1988 through 1998. Cases were defined as all persons who had a first-time recording of an Achilles tendon rupture, and who had at least 18 months of valid history before the index date. As a control group, we randomly sampled 50 000 patients with at least 18 months of valid history who were assigned a random date as index date.

 

RESULTS We identified 1367 cases that met the inclusion criteria. The adjusted odds ratio (OR) for Achilles tendon rupture was 4.3 (95% confidence interval [CI], 2.4-7.8) for current exposure to quinolones, 2.4 (95% CI, 1.5-3.7) for recent exposure, and 1.4 (95% CI, 0.9-2.1) for past exposure. The OR of Achilles tendon rupture was 6.4 (95% CI, 3.0-13.7) in patients aged 60 to 79 years and 20.4 (95% CI, 4.6-90.1) in patients aged 80 years or older. In persons aged 60 years and older, the OR was 28.4 (95% CI, 7.0-115.3) for current exposure to ofloxacin, while the ORs were 3.6 (95% CI, 1.4-9.1) and 14.2 (95% CI, 1.6-128.6) for ciprofloxacin and norfloxacin, respectively. Approximately 2% to 6% of all Achilles tendon ruptures in people older than 60 years can be attributed to quinolones.

 

CONCLUSIONS Current exposure to quinolones increased the risk of Achilles tendon rupture. The risk is highest among elderly patients who were concomitantly treated with corticosteroids.

AD

Pharmacoepidemiology Unit, Department of Epidemiology&Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands. 

PMID

12912715

114

|  PubMed

TI

Levofloxacin-associated Achilles tendon rupture and tendinopathy.

AU

Melhus A, Apelqvist J, Larsson J, Eneroth M 

SO

Scand J Infect Dis. 2003;35(10):768. 

 

Fluoroquinolones have a documented ability to induce Achilles tendinopathy. Hitherto, few published reports have implicated levofloxacin. This article reports 5 cases of Achilles tendon disorders, including 3 complicated by rupture of the tendon, during levofloxacin treatment of patients with chronic obstructive pulmonary disease.

AD

Department of Medical Microbiology, MalmöUniversity Hospital, Malmö, Sweden. asa.melhus@mikrobiol.mas.lu.se 

PMID

14606622

115

|  PubMed

TI

Fluoroquinolone-associated tendinopathy: a critical review of the literature.

AU

Khaliq Y, Zhanel GG 

SO

Clin Infect Dis. 2003;36(11):1404. Epub 2003 May 20. 

 

With the expanded use of fluoroquinolones for the treatment of community-acquired respiratory infections and reports of tendon injury linked to the use of these agents, we reviewed the literature to investigate the frequency and strength of this association. Ninety-eight case reports were available for review. The incidence of tendon injury associated with fluoroquinolone use is low in a healthy population but increases in patients who have renal dysfunction, who are undergoing hemodialysis, or who have received renal transplants. Pefloxacin and ciprofloxacin were most frequently implicated, but tendon injury was reported with most fluoroquinolones. The median duration of fluoroquinolone treatment before the onset of tendon injury was 8 days, although symptoms occurred as early as 2 hours after the first dose and as late as 6 months after treatment was stopped. Up to one-half of patients experienced tendon rupture, and almost one-third received long-term corticosteroid therapy. Tendon injury associated with fluoroquinolone use is significant, and risk factors such as renal disease or concurrent corticosteroid use must be considered when these agents are prescribed.

AD

Department of Pharmacy, Ottawa Hospital General Campus, Ottawa, Canada. 

PMID

12766835

116

 

 

http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm121598.htm (Accessed on April 23, 2012).

 

no abstract available

117

|  PubMed

TI

Impact of age, sex, obesity, and steroid use on quinolone-associated tendon disorders.

AU

Wise BL, Peloquin C, Choi H, Lane NE, Zhang Y 

SO

Am J Med. 2012;125(12):1228.e23. 

 

BACKGROUND Quinolone antibiotics are associated with increased risk of tendinopathy. Identifying at-risk individuals has important clinical implications. We examined whether age, sex, glucocorticoid use, obesity, diabetes, and renal failure/dialysis predispose individuals to the adverse effects of quinolones.

 

METHODS Among 6.4 million patients in The Health Improvement Network (THIN) database, 28,907 cases of Achilles tendonitis and 7685 cases of tendon rupture were identified in a case-crossover study. For each participant, we ascertained whether there was a prescription of a quinolone and comparison antibiotic within 30 days before the diagnosis of tendon disorder (case period) and a prescription of the same medications within 30 days 1 year before disease diagnosis (control period).

 

RESULTS Use of quinolones was strongly associated with an increased risk of Achilles tendonitis (odds ratio [OR], 4.3; 95% confidence interval [CI], 3.2-5.7) and tendon rupture (OR, 2.0; 95% CI, 1.2-3.3). No association was found between the use of other antibiotics and either outcome. The association with Achilles tendonitis was stronger among participants who were aged more than 60 years (OR, 8.3 vs 1.6), who were nonobese (OR, 7.7 vs 2.4), and who used oral glucocorticoids (OR, 9.1 vs 3.2). The association was nonsignificantly stronger in women (OR, 5.0 vs 3.6), diabetic persons (OR, 7.0 vs 4.1), and those in renal failure or receiving dialysis (OR, 20.0 vs 3.9). The effect for tendon rupture was stronger in women, with borderline significance in glucocorticoid users and nonobese persons.

 

CONCLUSION Quinolone-associated tendinopathy is more pronounced among elderly persons, nonobese persons, and individuals with concurrent use of glucocorticoids.

AD

University of California, Davis School of Medicine, Sacramento, CA 95817, USA. barton.wise@ucdmc.ucdavis.edu 

PMID

23026288

[cbrsmurf]

3 hours ago, Cideous said:

I have written literally thousands of quinolone scripts.  Never seen it one time.  Not once.

What specialty are you in where you have prescribed thousands of fluoroquinolones?

[sas5814]

I'm in primary care/family medicine and I have written thousands of quinolone scripts. Pneumonia, sinusitis, UTI, prostatitis. It was a go-to big hammer for a long time.

[mgriffiths]

I've been in Family Practice for almost 1 year, and while I try to avoid fluoroquinolones I do write them when needed.  I have seen one achilles tendon rupture that was likely related to quinolone prescription, and another patient who suffered tendon rupture also blamed on quinolone.

I tell every patient (and chart telling them) no strenuous activity, not a good time to start basketball or tennis...when starting a fluoroquinolones.  Whether either tendon rupture was actually related to the antibiotic or not, you open yourself up to lawsuit if you don't discuss and chart if the patient has a problem.

[Reality Check 2]

Also - remember to avoid these drugs in the several months after a rotator cuff repair, total joint replacement or other major surgery involving muscle cutting. I would hate to see a patellar tendon rupture in a fresh total knee due to Cipro or Levaquin.

Unless the infection is so dramatic that these are the only solution -  take care.

Elderly patients also have a risk for CNS involvement including giddiness, altered mental status or anxiety - it is in the package warning and is worse in elderly.

Also, never in kids. A local UC had a provider giving Cipro to 14 and 16 yr old girls for simple UTIs - WTH????

[Walkoffshot]

Completely anecdotal but we have seen/treated 2 Achilles tendon ruptures in the last year in our Ortho practice that we repaired in otherwise healthy young (30-40 y/o) males with a recent history of fluoroquinolone use. One was from playing basketball and another was from a direct injury to the Achilles. Can’t say forsure it was from the quinolone but likely was a contributor. We have treated a handful of patient with Achilles tendinitis, cuff tendinitis, epicondylitis with recent quinolone use as well. Our standard practice is advising the patient to avoid ballistic activities for a period of time (dependent on initiation of quinolone and symptom onset). Agree with above that the risks should be layed out clearly and ballistic activities should be avoided. Obviously try an alternative abx if possible. In my opinion if the patient needs it then they need it but should understand the risks and how to avoid injury.

[Guest ERCat]

I have seen two cases in the last year, one in an old man and one in a young woman. I try to avoid these meds when I can but most of the time it isn’t avoidable due to their allergies, culture sensitivities, etc.

[Cideous]

18 hours ago, cbrsmurf said:

What specialty are you in where you have prescribed thousands of fluoroquinolones?

25 years of EM and Urgent care.

In the late 90's there was a TON of Quin's on the market.  Most are gone now or rarely used generics, and a few were removed after liver issues surfaced.  But yea, we use to write a ton every single day.

[ventana]

have seen at least 3 cases - you need to ask to find them....  one resulted in tendon rupture....

 

also, i just about NEVER write for fluoroquinolones - they are such a huge gun Abx - I try to use more focused therapy.

 

leave the big guns for when you really really need them....

 

 

 

 

[cinntsp]

It is more common than originally thought.  I tend to avoid them in geriatric patients and anyone on systemic steroids. 

[entpac]

I have written for fluoroquinolones, even with steroids on rare occasions, and always counsel appropriately and document.  I have a standard paragraph that I use when charting.  This is reviewed with the patient verbally, word for word, then printed as "patient instructions."  In the clinical note I document the "patient verbalized understanding."  EMR makes this a little less time consuming and the patient takes paperwork home for reference.  Tendinopathy is more commonly encountered in our practice; I have never personally seen tendon rupture.  I also counsel about the potential for increased blood pressure, insomnia/ personality changes, increase blood sugar and possible avascular necrosis with steroids.  I document this every time although I have never seen avascular necrosis of the hip.  Others in our practice have started using a standard education paragraph similar to mine.  

[surgblumm]

It's a black box warning and therefore can be used in court by the plaintiff. How often does it happen? less than 0,5%. What can you do to cover yourself? As suggested, tell the patient to refrain from strenuous activity for three months. Harsh? Yes, Necessary, Yes.

[dht88169]

Our hospitalist service, at a small hospital has had 1 tendon rupture in the last year. We try to minimize the use of levaquin, besides in our area resistance to it is pretty high, especially when compared to cephalosporins.