From the Guidelines
Antibiotic-induced tendinitis, particularly with fluoroquinolones, requires immediate discontinuation of the offending antibiotic and alternative management to prevent further tendon damage. The risk of tendinitis is increased in patients with a history of tendon disorders, those aged over 60 years, and individuals taking concomitant corticosteroids 1. Management strategies include:
- Resting the affected tendon
- Applying ice to reduce inflammation
- Elevating the limb when possible
- Using over-the-counter NSAIDs like ibuprofen or naproxen to manage pain and inflammation
- Considering physical therapy during recovery, which can take 2-6 weeks or several months in severe cases It is essential to avoid corticosteroid injections, as they may worsen tendon damage 1. Prevention is crucial for high-risk patients, and alternative antibiotics should be considered when possible. The mechanism of fluoroquinolone-induced tendinopathy involves disruption of tendon structure, increasing matrix metalloproteinases and reducing collagen production 1. In severe cases, complete tendon rupture may occur, requiring orthopedic evaluation and possibly surgical intervention, particularly in weight-bearing tendons like the Achilles. Ceasing all quinolone treatment is recommended if tendinitis is suspected, and patients should be closely monitored for signs of tendon damage 1.
From the FDA Drug Label
WARNINGS Tendinopathy and Tendon Rupture: Fluoroquinolones, including Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg, are associated with an increased risk of tendinitis and tendon rupture in all ages. Patients should be advised to rest at the first sign of tendinitis or tendon rupture, and to contact their healthcare provider regarding changing to a non-quinolone antimicrobial drug.
The recommendations for managing antibiotic-induced tendinitis, particularly with fluoroquinolones, are to:
- Discontinue the fluoroquinolone therapy if the patient experiences pain, swelling, inflammation, or rupture of a tendon.
- Rest at the first sign of tendinitis or tendon rupture.
- Contact the healthcare provider regarding changing to a non-quinolone antimicrobial drug.
- Be aware that the risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in older patients, in patients taking corticosteroid drugs, and in patients with kidney, heart, or lung transplants.
- Consider alternative treatments for patients with a history of tendon disorders, such as rheumatoid arthritis, or those who have experienced tendinitis or tendon rupture with previous fluoroquinolone use 2.
From the Research
Recommendations for Managing Antibiotic-Induced Tendinitis
- The management of antibiotic-induced tendinitis, particularly with fluoroquinolones, involves immediate discontinuation of the offending antibiotic 3, 4, 5, 6, 7.
- Rest, non-steroidal anti-inflammatory drugs, physical modalities, and eccentric strengthening exercise are recommended for the treatment of fluoroquinolone-associated tendinopathy 7.
- Tendon rupture may require surgical intervention 7.
Risk Factors for Antibiotic-Induced Tendinitis
- Older age (older than 60 years) is a risk factor for fluoroquinolone-associated tendinopathy 4, 5, 6.
- Concomitant use of corticosteroids increases the risk of tendon injury 4, 5, 6.
- Receipt of concomitant corticosteroid therapy, presence of renal dysfunction, and history of solid organ transplantation are also risk factors for fluoroquinolone-associated tendinopathy 5.
Fluoroquinolones and Tendinitis
- All fluoroquinolones are associated with an increased risk of tendinitis and tendon rupture, but the risk varies depending on the specific fluoroquinolone used 3, 4, 5, 6.
- Ciprofloxacin has been associated with a high risk of tendonitis 3, 7.
- Levofloxacin has been associated with a high risk of tendon rupture 3, 5.
- Ofloxacin has been associated with a high risk of tendon injury 4, 5, 6.