Cipro and my Achilles tendons (Read 1572 times)

    Hi, all.  I just started a ten day cycle of the antibiotic Cipro for a bladder infection.  One of the cautions for Cipro is the potential for ruptured tendons.  I have chronic Achilles problems - never a tear, but inflammation and pain.  Both tendons are almost always sensitive to the touch and my running has, at times, been limited.  At their worst about a year ago, I had an MRI.  There was no tear and the doctor said I could continue running if I could tolerate it.  Sometimes it's bad and I'm usually limited to not much more than 20 miles per week.  Other background:  I'm a 44 year-old male with about 20 pounds I'd like to lose.  


    My question:  do I really have to stay home on this beautiful day?  I want to run, but not if I'm going to pop an Achilles.



    Yeah, well...sometimes nothin' can be a real cool hand.

    Rod Staples

      I have dealt with a similar problem I was given the drug Lavaquin for my sinus infection it got rid of my infection but  for a year after I have dealt with pulled Hamstrings sore Achilles and border line tears. If you are an active person I would recommend doing something different than a Cipro drug but since you have it in your system now I would tred lightly.  I Bicycled alot and cross trained to stay active.  This drug attaches itself to the tendons and stays there for a long time.  I even asked the Pharmacist and He told me not to worry but that is not the case.  Check it out on the Web all the Law suits going after this Drug.  Good luck!  So far this year I have bumped up my mileage with minor problems my goal is to hit 1600 for this year I'am 55.

        Rod, thanks for your response.  Wow.  I didn't know the effects could linger beyond the antibiotic cycle.  I knew Cipro was a strong antibiotic but I didn't think it was a big deal.  I'm told bladder infections are uncommon in men, so I figured that played into the choice.  


        This is the second time I have been on Cipro, so now I'm wondering if it has actually contributed to my Achilles issues. 


        Trent, if you're out there, could you weigh in?



        Yeah, well...sometimes nothin' can be a real cool hand.

          The drug does not bind to the tendons ... there are no binding sites on the tendons for fluoroquinolone antibiotics, which cipro is a member of.  These antibiotics are metabolized and cleared from the body, they do not hang around for a long time.  Perhaps you over-trained and thus have problems.  You are so quick to blame the physician and pharmacist and drug.  Why don't you stick with making statements in your field of expertise.

          12 Monkeys

            Gaspasser, what is the mechanism of action by which fluoroquinolones cause the tendon rupture for which they are associated, and for which there is a black box warning


            To be clear, even the FDA has implicated (i.e., passed "blame" on) the drug. So Gasspasser, please, share with us where exactly either of the prior posters implicated the physician or the pharmacist. 

            12 Monkeys

              I'm wondering if it has actually contributed to my Achilles issues.


              Hard to know for sure.  Clearly, this class of medications is associated with tendon irritation and rupture.  The precise mechanism of action is unknown, and so there is a lot of prognostic uncertainty.  Generally speaking, if you have a history of tendonitis, you should try and avoid this medication class.

              The drug probably does not directly attach itself to the tendons, but its predisposing you to tendonitis may linger.

                I can attest to it possibly revealing a past injury from experience.. had Achilles tendinosis 6 years ago which knocked me out of HS cross country, but was given Cipro last year for what was suspected as a swollen lymph node. Probably 7 days into taking it I felt my (previously injured) achilles getting quite sore. Luckily I had done a little research and based on my past injury I had planned those 2 weeks really easy before popping the first dose and did more cross-training, conveniently it was finals week. I didn't have any lingering pain after stopping the Cipro. I will admit it scared the bejesus out of me. Mostly because I invested 9 months of time in 5 day/week physical therapy and it took a while to lose the chub I gained while injured, and couldn't take that again.



                    Quinolones inhibit the bacterial DNA gyrase ( topoisomerase II enzyme), thereby inhibiting DNA replication and transcription.


                    They do not bind to the tendon, but I do not think the mechanism of tendon rupture is well elucidated.  If there is concomitant tendon injury, I agree with you Trent, one should avoid the drug as to not muddy the picture.  A previous poster seemed to blame the pharmacist that said "don't worry, it will be okay to take the drug."  Society seems quick to blame the health care system.  Perhaps the previous poster over-trained and there was a temporal relationship, but not a causal one.


                    A case-control study of more than 46,000 users of fluoroquinolones in the Netherlands found 704 fluoroquinolone-treated patients with Achilles tendinopathy, of whom 38 had Achilles tendon rupture. The relative risk of tendon disorders attributable to fluoroquinolone use was 1.9 (95% CI, 1.3 to 2.6), and the excess risk among patients treated with fluoroquinolones was approximately 3 cases per 1000 patient-years of exposure. The risk was highest among patients over the age of 60 years receiving glucocorticoids. A population-based case-control study in the United Kingdom found similar results. Kidney, heart, and lung transplantation have been identified as additional risk factors. The median duration of fluoroquinolone use before the onset of tendon injury is eight days. The risk of tendinopathy may be exposure-related; dosages should be adjusted based on renal function to avoid possible drug accumulation.


                    Zofran and droperidol are still given for post-op nausea and vomiting despite black box warnings of QT prolongation.  Everything is a risk/benefit ratio in medicine.


                    The references I used are:


                    van der Linden PD, Sturkenboom MC, Herings RM, et al. Fluoroquinolones and risk of Achilles tendon disorders: case-control study. BMJ 2002; 324:1306.


                    van der Linden PD, Sturkenboom MC, Herings RM, et al. Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids. Arch Intern Med 2003; 163:1801.


                    Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis 2003; 36:1404.


                    Mehlhorn AJ, Brown DA. Safety concerns with fluoroquinolones. Ann Pharmacother 2007; 41:1859.


                      i was on a whole bunch of stuff last year includin cipro. i was advised to stop runnin durin and aftah treatment. durin i did, aftah i did not but my pace was slow and mileage was cut (aside from the burden of havin to run a marathon)and did a lot of swimmin and bikin to make up the slack. it's really hahd to tell how somethin's gonna effect ya or if it even will. just don't go blastin it...not that you should anyways with the pain of a chronic cond.


                      and doesn't runnin feel horrible anyways w/a bladdah infection? othah events can steer you into an excitin new direction and take some of the pressure off that AT.


                      mta; oh and i've had AT/PF issues for well ovah a year now.

                      In order to see the truth, sometimes you have to loose an eye.










                        Everything is a risk/benefit ratio in medicine.


                        I agree with you on this.


                        Otherwise I see no reason to defend antibiotics in response to the OP's questions. Your references don't adequately address the issues specific to running. Thank you for providing additional and alternative data to the discussion, though.


                        My Achilles trouble happened in the months following the removal of my wisdom teeth, which is noteworthy because I had to take an antibiotic at the time. I think that coincidence and a million other factors are at play, but you can count me among the wary.

                        12 Monkeys

                          Society seems quick to blame the health care system.


                          Perhaps.  But this was fairly harsh:


                          Why don't you stick with making statements in your field of expertise.


                          And I agree with Xeno, your discussion and lit review is useful, but does not directly address the question.  As you point out, there is a lot we don't know about achilles tendon rupture or other tendonopathy/myopathy and quinolones.

                            Thanks, everyone, for the continued dialogue.  I am always appreciative of people smarter than me, lol.  


                            Update:  worsening pain, a trip to my doctor, and a scan have revealed the real culprit - a kidney stone.  One hellish day later and I have passed the stone.  So now I have a Percocet hangover and half a cycle of Cipro left.  


                            My Achilles issues predate the Cipro, but I will still come back cautiously.  Unless it's a horrible idea, I may even run lightly tomorrow.  


                            One thing that frustrates me is the mind-boggling list of potential side-effects on some of these medications:


                            "may cause diarrhea...but may also cause constipation."

                            "may cause drowsiness...but may also cause agitation."


                            All they do is confuse me.  Warn me of the risk of "an erection lasting more than four hours" and I'll roll the dice.  Just don't mess with my Achilles.

                            Yeah, well...sometimes nothin' can be a real cool hand.

                              I would love to learn about the exact mechanism of fluoroquinolones and tendon problems.  With respect to the risk/benefit ratio, I think it is agreed upon from the referenced studies that tendon problems are in the minority of patients.  Perhaps an infection that is best treated with a fluoroquinolone as evidenced by MIC/lab data .... one may make a certain prescribing decision.  In the age of defensive medicine and the absence of a strong indication for a fluoroquinolone, it seems totally reasonable that a physician would avoid prescribing that class of antibiotics to an athlete.  That is the inherent problem with outpatient medicine, where patients are not monitored and it is more difficult to ascertain the underlying cause of a complication.  Obviously, the best interest of the patient should be taken to heart along with treating whatever medical malady they present with.  Great discussion and I hope all of the posters on this thread have a safe, injury free, and enjoyable Thanksgiving holiday! :-)

                              12 Monkeys

                                Yeah, Outpatient medicine is hard.  There tends to be a lot of uncertainty, high volume, a need for tremendous efficiency, a lack of MIC data, and a need to accomodate patients lifeflow needs.  Fluoroquinolones are often the best choice, especially among male patients who have clinical evidence of a UTI or epididymitis, or certain respiratory infections.  But there are typically alternatives to consider, especially in athletes.

                                While I am dain to refer to anecdote, I personally developed myopathy and tendonopathy when taking levafloxacin.  The medication was one of two antibiotics that were the best choice at the time when considering risk : benefit.  I switched to the other, but it took a while for my tendons to recover.  Good times!