Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature

Abstract

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.

Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain

“…The various predisposing risk factors related to Achilles tendinopathy that are suggested as being important in the literature are listed in Table 2 (Clement et al, 1984, Lysholm and Wiklander, 1987, Hess et al, 1989, Kvist, 1991, Haglund-Åkerlind and Eriksson, 1993, Kvist, 1994, DeMaio et al, 1995, Kannus, 1997a, Alfredson et al, 1998a, Kaufman et al, 1999, McCrory et al, 1999, van der Linden et al, 1999, Järvinen et al, 2001, Kader et al, 2002, Paavola et al, 2002a, Khaliq and Zhanel, 2003, Järvinen et al, 2005, Mahieu et al, 2005, Alfredson and Öhberg, 2005c. …”

“…Predisposing extrinsic factors are thought to be training errors, changes in training surface and ineffective or improper footwear, as well as the sideeffects of drug treatment such as fluoroquinolones (Clement et al, 1984, Hess et al, 1989, Nichols, 1989, Galloway et al, 1992, Kvist, 1994, DeMaio et al, 1995, Kannus, 1997a, van der Linden et al, 1999, Järvinen et al, 2001, Kader et al, 2002, Paavola et al, 2002a, Khaliq and Zhanel, 2003, Järvinen et al, 2005. The excessive loading of the Achilles tendon and training errors such as increasing intensity and duration too quickly are reported to be present in 60-80% of patients with Achilles tendinopathy (Kvist, 1991, Kvist, 1994, Järvinen et al, 2001, Järvinen et al, 2005.…”

“…The use of fluoroquinolone antibiotics (normally used in respiratory infections) has been implicated in tendinopathy and tendon ruptures (van der Linden et al, 1999, Khaliq andZhanel, 2003). In a literature review, Khaliq and Zhanel (2003) found the incidence of Achilles tendinopathy in a healthy population using fluoroquinolone to be low, but increases were found in patients who had renal dysfunction, were undergoing hemodialysis, or had received renal transplants.…”

“…In a literature review, Khaliq and Zhanel (2003) found the incidence of Achilles tendinopathy in a healthy population using fluoroquinolone to be low, but increases were found in patients who had renal dysfunction, were undergoing hemodialysis, or had received renal transplants. They also report that the median duration of fluoroquinolone treatment before onset was 8 days, although it could start as early as 2 hours after the first dose and as late as 6 months after treatment.…”

Synergistic effects of dexamethasone and quinolones on human-derived tendon cells

“…The use of quinolones has increased during recent years because of the increasing resistance of pneumococci and other bacteria tolactams and macrolides [1]. Tendinopathies are rare but severe side effects that have been observed for both classes of drugs [2][3][4][5][6][7][8][9][10]. The term 'tendinopathy' comprises several forms of tendon damage from a reversible inflammation (tendinitis) up to tendon rupture requiring surgical intervention.…”