About the Authors
K. Ashley Garling, PharmD, is a clinical assistant professor at The University of Texas at Austin College of Pharmacy.
RahJewel K. Barnhill is a 2027 PharmD candidate at The University of Texas at Austin College of Pharmacy.
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When to Call, When to Counsel: Fluoroquinolone Tendinopathy
A collaborative health care approach enhances patient outcomes and supports informed decision-making in antibiotic management.
Introduction
The increasing utilization of prescription medications necessitates that pharmacists remain vigilant in determining the clinical relevance of common adverse drug reactions (ADRs). The decision-making process is often multifaceted and can require a variety of interventions, from therapeutic changes to comprehensive patient counseling. One significant yet often underestimated ADR is the risk of medication-induced tendinopathy, particularly associated with fluoroquinolone antibiotics.1,2
Runner holding their heel | Image credit: Oleg Breslavtsev | stock.adobe.com
Fluoroquinolones have many indications, including urinary tract infections; hospital-acquired pneumonia; and specific skin, bone, and joint infections. The benefits of fluoroquinolones are their high oral bioavailability, minimal pill load, superior tissue penetration, and broad-spectrum bacteria coverage. However, it is crucial to remember that this family of antibiotics also heightens the risk of tendinopathy and tendon rupture, particularly the calcaneal tendon, also called the Achilles tendon, which attaches the calf muscle to the heel bone.3
Tendinopathy is the overarching term that covers tendon-related chronic conditions. Tendonitis is the inflammation of the tendon that is typically acute in nature, tendinosis is the breakdown of the tendon, and tendon rupture is a break or tear of the fibrous tendon that connects bone to muscle. Research shows that fluoroquinolones can weaken the collagen matrix within tendons, making the tendon more susceptible to damage and increasing the risk of tendon rupture.2 Therefore, caution should be exercised when prescribing fluoroquinolones, especially to high-risk groups.
The repercussions of tendon rupture can be severe, especially for high-risk groups such as older adults, patients with chronic conditions, athletes, or those taking corticosteroids.4,5 These ruptures can cause significant pain and impaired mobility and may necessitate surgical intervention with extended recovery periods.6 Tendinopathy can develop quickly—sometimes within days or even after a single dose—with certain groups facing a much higher risk. Individuals over 60 years of age are over twice as likely to experience a tendon rupture, and for those also taking corticosteroids, the risk is more than 6 times higher.4,5 In 90% of cases, the Achilles tendon is affected, and nearly half of those experience tendon damage in both legs.2,6
The degenerative changes primarily occur in the body of the tendon rather than at its attachment points, leading to a rupture in approximately 40% of cases, often within just 2 weeks of symptom onset.2,7 The severity of these ruptures cannot be overstated, and it is crucial to take proactive measures to prevent them. Physical stress on the Achilles tendon should be minimized for 6 weeks to 6 months after injury, while recovery can take anywhere from weeks to months.5 Due to the severity of tendinopathy and tendon rupture with fluoroquinolone use, pharmacists must be comfortable with the clinical decision to call the physician or counsel the patient.
When to Call a Physician or Refer a Patient
Always refer a patient to be seen by a physician if they are experiencing an acute injury, including sudden weakness, pain, swelling, bruising, burning, stiffness, hearing a popping noise at the time of injury, inability to utilize, or visible deformity of the body part. It is of utmost importance for patients to consult a physician before self-medicating, because medications such as steroids and non-steroidal anti-inflammatory drugs can interfere with healing. Tendinopathy and rupture can be progressive, causing tendon cell death, which compromises the tissue structure. This can lead to pathologies such as abnormal blood vessel formation and disorganized cellular growth, which can, in turn, complicate recovery.4
What To Tell the Physician
When calling a physician, always identify yourself and the patient; start by reminding the physician of the medication they prescribed and the date the prescription was written. It is also important to provide the physician with the patient's diagnosis, as this helps the physician understand the context and expedite the call. Diagnosis codes are frequently found on e-prescriptions or by asking the patient. Never assume the physician knows or remembers the patient's medical history or daily activities, such as physical activities. Give a concise recount of the risk factors, including current physical activity or sports, upcoming events or training, previous injuries or tendinopathy, and any other contributing medications that would increase the patient's risk. Patients actively training for running, cycling, or weightlifting may be at a higher risk of Achilles tendon rupture than other patients. Additionally, older adults, patients taking higher doses and longer duration of antibiotics, individuals living with chronic kidney disease, those taking steroids both acutely or chronically, and those on other medications that may cause tendonitis are also at risk.4,5
If a patient does not have a reasonable option to stop their current physical activity or medications or has pre-existing injuries, have alternative antibiotics to recommend to the physician.1 Always ensure your alternatives cover the condition's commonly associated bacteria and complexity level (uncomplicated vs. complicated). It may be pertinent to have 2 recommended therapies, including dose and length of use, in the case of drug resistance to your primary option. Resources for alternative treatments for common bacterial infections can be found in Table 1.1
Ultimately, a collaborative health care approach enhances patient outcomes and supports informed decision-making in antibiotic management. It underscores the importance of a multidisciplinary team in managing complex conditions and optimizing antibiotic use. In this way, pharmacists are indispensable in bridging the gap between medication management and patient care, contributing to a safer and more effective health care system.
TABLE 1. Oral Fluoroquinolone Use and Alternative Therapies1
When to Counsel
Pharmacists should counsel all patients prescribed fluoroquinolone antibiotics regarding safe activities during treatment. It is crucial to remember that tendon-related symptoms can emerge within just a few days of starting therapy and these symptoms can be severe, underscoring the urgency and seriousness of the issue.2,7 Even patients who may not seem at risk, such as those under 60 years of age, those without a history of tendinopathy, and those without chronic conditions, should still be counseled.
Patient education should include symptoms to look for, when tendinopathy might occur, where on the body tendinopathy is most likely, and the importance of monitoring for symptoms (see Table 2). The pharmacist should focus on discussing the potential risks of tendon damage associated with the antibiotic while emphasizing the significance of recognizing early symptoms.2,8 Patients should be counseled to avoid activities that might put excess stress on their tendons and should be encouraged to report any unusual symptoms, such as pain, swelling, bruising, or stiffness, as soon as they occur. The pharmacist should also emphasize the importance of stopping the medication and consulting their physician if symptoms appear, as early intervention can help prevent further injury. Additionally, pharmacists should encourage patients to report any adverse events through the FDA Adverse Event Reporting System.7 Monitoring and reporting these events is essential to help track and understand the impact of fluoroquinolone-related tendon injuries on patients.
TABLE 2. Five W’s of Patient Counseling with Oral Fluoroquinolones
Conclusion
Pharmacists play a vital role in patient safety by monitoring for ADRs, particularly tendinopathy linked to fluoroquinolone use. Given high-risk factors such as age, concurrent therapies, and activity levels, pharmacists should communicate clearly with both patients and health care providers.2,4 By recognizing early signs of tendinopathy and knowing when to escalate care, pharmacists help prevent severe complications such as tendon rupture, which can significantly affect a patient’s quality of life. Such preventative measures are beneficial for immediate patient health and long-term outcomes because they help maintain mobility and functionality. Furthermore, the timely identification of ADRs can lead to adjustments in therapy, enhancing the overall treatment plan. Pharmacists also play a crucial role in patient education, providing detailed information about their medication, possible adverse effects, and instructions on what to do if symptoms occur. By empowering patients with knowledge, pharmacists ensure they are active participants in their health care, thereby enhancing patient safety.
References
Fluoroquinolones. Facts and Comparisons eAnswers [database online]. St. Louis, MO: Wolters Kluwer Health, Inc.; insert current year of copyright. Available at: http://online.factsandcomparisons.com/index.aspx/. Accessed October 2024
Alves, C., Mendes, D., & Marques, F. B. (2019). Fluoroquinolones and the risk of tendon injury: A systematic review and meta-analysis. European Journal of Clinical Pharmacology, 75(11), 1431–1443. https://doi.org/10.1007/s00228-019-02713-1
Godoy-Santos, A. L., Bruschini, H., Cury, J., Srougi, M., de Cesar-Netto, C., Fonseca, L. F., et al. (2018). Fluoroquinolones and the risk of Achilles tendon disorders: Update on a neglected complication. Urology, 113, 20-25.
Persson, R., & Jick, S. (2019). Clinical implications of the association between fluoroquinolones and tendon rupture: The magnitude of the effect with and without corticosteroids. British journal of clinical pharmacology, 85(5), 949–959. https://doi.org/10.1111/bcp.13879
Morales, D.R., Slattery, J., Pacurariu, A. et al. Relative and Absolute Risk of Tendon Rupture with Fluoroquinolone and Concomitant Fluoroquinolone/Corticosteroid Therapy: Population-Based Nested Case–Control Study. Clin Drug Investig 39, 205–213 (2019). https://doi.org/10.1007/s40261-018-0729-y
Pantalone, A., Abate, M., D’Ovidio, C., Carnevale, A., & Salini, V. (2011). Diagnostic failure of ciprofloxacin-induced spontaneous bilateral Achilles tendon rupture: Case-report and medical-legal considerations. International Journal of Immunopathology and Pharmacology, 24(2), 519-522.
Arabyat, R. M., Raisch, D. W., McKoy, J. M., & Bennett, C. L. (2015). Fluoroquinolone-associated tendon-rupture: a summary of reports in the Food and Drug Administration’s adverse event reporting system. Expert Opinion on Drug Safety, 14(11), 1653–1660. https://doi.org/10.1517/14740338.2015.1085968
Rusu, A., Munteanu, A. C., Arbănași, E. M., & Uivarosi, V. (2023). Overview of Side-Effects of Antibacterial Fluoroquinolones: New Drugs versus Old Drugs, a Step Forward in the Safety Profile?. Pharmaceutics, 15(3), 804. https://doi.org/10.3390/pharmaceutics15030804
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