What medications can cause Achilles tendonitis or tendinopathy?

From the Guidelines

Fluoroquinolone antibiotics, such as ciprofloxacin, levofloxacin, moxifloxacin, and ofloxacin, are the primary medications that can cause Achilles tendon issues, including tendinitis and tendon rupture, due to their potential to weaken tendon structure by affecting collagen production and increasing enzymes that break down tendon tissue 1.

Key Points to Consider

• The risk of tendon damage is highest within the first month of treatment but can occur even after stopping the medication.
• Risk factors include being over 60 years old, taking corticosteroids concurrently, having kidney disease, or previous organ transplantation.
• Other medications that may affect tendon health include statins (cholesterol-lowering drugs), corticosteroids, and aromatase inhibitors used in breast cancer treatment.
• If symptoms such as sudden Achilles pain, swelling, or difficulty walking occur, it is crucial to contact a healthcare provider immediately for early intervention to prevent complete rupture.

Important Considerations

• Fluoroquinolones are contraindicated in patients with a history of tendon disorders related to quinolone use, and caution is advised in patients with certain medical conditions, such as liver disease or cardiovascular issues 1.
• The use of fluoroquinolones in children and growing adolescents is contraindicated due to the risk of arthropathy, as evidenced by studies in young animals 1.
• It is essential to weigh the benefits and risks of fluoroquinolone use, considering the potential for tendon damage and other adverse effects, especially in vulnerable populations 1.

From the FDA Drug Label

Fluoroquinolones, including levofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all ages. This adverse reaction most frequently involves the Achilles tendon, and rupture of the Achilles tendon may require surgical repair Tendinitis and tendon rupture in the rotator cuff (the shoulder), the hand, the biceps, the thumb, and other tendon sites have also been reported. 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. This adverse reaction most frequently involves the Achilles tendon, and rupture of the Achilles tendon may require surgical repair

Medications that can cause Achilles tendonitis or tendinopathy:

• Fluoroquinolones, including:
  • Levofloxacin 2
  • Ciprofloxacin 3, 3 It is recommended to discontinue the use of these medications if the patient experiences pain, swelling, inflammation, or rupture of a tendon. 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.

From the Research

Medications Associated with Achilles Tendonitis or Tendinopathy

• Fluoroquinolone antibiotics, such as:
  • Levofloxacin 4, 5
  • Ciprofloxacin 6, 7
  • Ofloxacin 6
  • Norfloxacin 6
  • Pefloxacin 6
• Concomitant use of corticosteroids with fluoroquinolones increases the risk of tendon rupture 4, 8

Risk Factors

• Age: patients over 60 years of age are at higher risk 6, 8
• Concomitant use of corticosteroids 4, 8
• Female sex 8

Clinical Presentation

• Bilateral heel pain 4
• Swelling and tenderness of the Achilles tendons 4
• Partial or complete tendon rupture 6, 5, 7
• Onset of symptoms can occur within 1-510 days after starting fluoroquinolone therapy 6