What is the risk of tendon rupture associated with Ciprofloxacin (ciprofloxacin) use?

Ciprofloxacin and Tendon Rupture Risk

Ciprofloxacin significantly increases the risk of tendon disorders, particularly Achilles tendon rupture, with a 3-4 fold higher risk compared to the general population, though the absolute risk remains relatively low at approximately 12 cases per 100,000 persons within 90 days of treatment. 1, 2

Risk Quantification

• Current use of ciprofloxacin and other fluoroquinolones increases the risk of tendon disorders (odds ratio 1.7), tendon rupture (odds ratio 1.3), and specifically Achilles tendon rupture (odds ratio 4.1) 3
• The absolute risk is approximately 1 case of Achilles tendon rupture per 5,958 patients treated with fluoroquinolones 3
• The risk is highest within the first 30 days of treatment, with most cases occurring within the first week (median 6 days) of exposure 3, 1
• While the relative risk is increased 3-4 fold, the absolute increase in risk is approximately 12 cases per 100,000 persons within 90 days of fluoroquinolone treatment 3, 1

Risk Factors That Increase Tendon Rupture Probability

• Age over 60 years: Risk increases to 1 Achilles tendon rupture per 1,638 fluoroquinolone-treated patients (4 times higher risk compared to general population) 3, 1
• Concomitant corticosteroid use: Dramatically increases risk to 1 in 979 patients (odds ratio 43.2) 3, 1
• Other risk factors that may independently increase risk include: 3
  • Participation in sports or physical activity
  • Renal failure
  • Organ transplantation
  • Pre-existing tendon disorders
  • Rheumatoid arthritis and other inflammatory conditions
  • Diabetes mellitus
  • Magnesium deficiency

Anatomical Distribution and Clinical Presentation

• The Achilles tendon is most commonly affected (90% of cases), but other tendons may also be involved 3, 1
• Other affected tendons include patellar tendon, rotator cuff tendons, and hand/foot tendons 3, 4
• Bilateral tendon involvement occurs in more than 50% of cases 3
• Pain is the most commonly reported symptom, with most patients recovering within 2 months of discontinuing the fluoroquinolone 3, 5

FDA Warnings

• The FDA has issued a boxed warning stating: "Fluoroquinolones, including ciprofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all ages. This risk is further increased in older patients usually over 60 years of age, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants." 4
• The FDA recommends discontinuing ciprofloxacin if a patient experiences pain, swelling, inflammation, or rupture of a tendon 4
• Tendon rupture can occur during or after completion of therapy; cases occurring up to several months after completion of therapy have been reported 4, 6

Prevention and Management

• For high-risk individuals (over 60 years, history of tendon disorders, athletes), consider alternative antibiotic classes when clinically appropriate 2
• Consider magnesium supplementation during fluoroquinolone treatment if no contraindications exist 2
• 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 4
• Management of fluoroquinolone-associated tendinopathy includes immediate discontinuation of the drug, rest, NSAIDs, and physical therapy 5
• Tendon rupture may require surgical intervention 5

Recent Research Developments

• A 2020 study of 1 million US Medicare beneficiaries found that not all fluoroquinolones carry the same risk. Levofloxacin showed increased risk of tendon ruptures, while ciprofloxacin did not demonstrate a significant increased risk of combined tendon ruptures (HR=0.96) 7
• This suggests potential differences in risk profiles among fluoroquinolones, though the FDA warning applies to the entire class 7