Tendon Damage From Fluoroquinolone Antibiotics

Ross Hauser, MDRoss Hauser, MD

As if there isn’t enough pain out there, now scientists have learned that fluoroquinolone antibiotics damage tendons. Yes, you can get wake up one day and all of a sudden you have pain in or around a joint just because you took an antibiotic.

Tendon Damage From Fluoroquinolone Antibiotics

Dick came to Caring Medical because of a severe left shoulder pain. There was no precipitating event except that he needed several rounds of Levoquin for a urinary infection because of a urethral stricture. On physical examination he had evidence of a supraspinatous tendinopathy (Rotator Cuff) which now was causing a frozen shoulder (adhesive capsulitis). Fortunately for Dick he came in early and only necessitated two prolotherapy treatments one month apart. He also received aggressive Physical therapy for the limitation of shoulder range of motion. Within six weeks of therapy he was back to swimming. He made a full recovery.

To show you the extent of damage that can occur with fluoroquinolones, a client named Amy came to Caring Medical convinced she had tendon and muscle injury from the antibiotics she took. She explained, “I had a respiratory infection so I was given Levoquin. After the infection was over I had pain all over my body and it hasn’t stopped!” After questioning Amy and examining here we did some blood work. She did not have Candida, but did have a high CPK level which can indicate muscle damage. I am now convinced that Amy was correct, she did get muscle and tendon damage all over her body from the fluoroquinolone antibiotic she received. She will soon be in for her second visit.

Fluoroquinolones are a class of synthetic antibiotics which have a broad spectrum of antibiotic activity that includes both Gram negative and Gram positive bacteria. Some of the more common ones are Levoquin (levofloxacin), Ciproxin (ciprofloxacin) other common drug names are Baloxin and Tequin, and common chemical names are enoxacin, lomefloxacin and norfloxacin. In the literature many side effects have been documented including tendonitis and subsequent tendon rupture. The incidence is felt to be between 0.14%-0.4% but if someone has other health conditions, the incidence can go up to 15.6%. Advanced age seems to be the most significant risk factor. Long periods of hemodialysis, diabetes mellitus, hyperparathyroidism, rheumatic diseases, gout, and corticosteroids are other predisposing factors.1, 2

To investigate the cause of tendon injury, researchers at the University of Berlin, Germany incubated human tendon cells with differing concentrations of ciprofloxacin and levoquin. They then looked at the cells under an electron microscope. At concentrations which are achievable during quinolone therapy, tendon synthesis of collagen was significantly decreased. The inhibition was dose-dependent. Effects were intensified at higher concentrations and longer incubation periods. If this isn’t bad enough, the researchers found that both fluoroquinolones induced apoptosis in the cells. Apoptosis means programmed cell death. This was confirmed by electron microscopy. In other words, fluroquinolones can cause the tendon cells to die prematurely! Their conclusion reads as follows: ‘Our results provide evidence that besides changes in receptor and signaling proteins apoptosis has to be considered as a final event in the pathogenesis of fluoroquinolone-induced tendinopathies’.3

Summary

What’s it all about, Alfie? Sometimes strong medications are needed. The doctor and patient must evaluate the risks and benefits before starting any theray. Fluoroquinolones are strong antibiotics. When they are prescribed, the doctor and user must be aware that tendon injury is a possibility. For those suffering from chronic tendon injuries, a treatment to consider is Prolotherapy. Prolotherapy stimulates the body to repair painful areas, such as tendon and ligament injuries. Prolotherapy to the injured tendon will induce a mild inflammatory reaction which is the body’s mechanism to repair injured areas. Prolotherapy causes a proliferation (thus the word prolo-) of the fibroblasts which make the collagen which makes up the ligament or tendon. Typically three to six sessions at four to six week intervals is the usual course. If you or someone you know and love has fluoroquinolone-induced tendon injury, tell them about Prolotherapy. Prolotherapy offers hope for people with this condition.

References:

  1. Muzi F, Gravante G, Tati E, Tati G. Fluoroquinolones-induces tendonitis and tendon rupture in kidney transplant recipients: 2 cases and a review of literature. Transplantation Proceedings. 2007; 39:1673-1675.
  2. Kempka G, Ahr HJ, Ruther W, Schluter G. Effects of fluoroquinolones and glucocorticoids on cultivated tendon cells in vitro. Toxicology in Vitro. 1996;10:743-754.
  3. Sendzik J, Shakibaei M, Schafer-Korting M, Stahlmann R. Fluoroquinolones cause changes in extracellular matrix, signaling proteins, metalloproteinases and caspase-3 in cultured human tendon cells. Toxicology. 2005;212:24-36.