Levofloxacin and the Risks of Tendon Injury

author : AMSSM

comments : 2

Information on how long the risk of tendon rupture persists after levofloxacin use is hard to find. Tendon rupture could occur as early as a few hours to as late as six months after the initial dose.

Member Question from QueenZipp

"What is the hard data, if any, on the effects of Levaquin on soft tissue injury?  I used this drug in January and again in May, along with steroids both times.  I have a gastrocs tear and am trying to find a correlation of how long the effect these medications can have on on tendons/ ligaments/ muscles.  The data I can find links the medicine to problems, but I have not found hard data on the length of time a person can have problems from it."

Answer by Michael Krafczyk, MD
Member AMSSM

Fluoroquinolones, the family of antibiotics to which Levaquin belongs, have from their introduction been associated with tendon rupture and tendinitis¹.  Early on the association was with the Achilles tendon, but with increasing use of these agents tendon ruptures in other areas have been reported².  The mechanism is thought to be an ischemic process (loss of blood supply).  Histopathologic studies show a lack of inflammatory cells and other findings typically seen with overuse injuries.  The findings are consistent with altered cellular function and tendon architecture¹.

Hard Data on Tendon Rupture Risk with Levofloxacin

The reported incidence rates for fluoroquinolones and tendon rupture range from 0.14% to 0.4%.  Reporting system data shows levofloxacin has a higher rate of tendon rupture than ciprofloxacin and norfloxacin³ - other flouroquinolone antibiotics.  Risk factors for tendon rupture associated with any fluoroquinolone appear to be concomitant steroid use, renal insufficiency, advanced age, prior tendonopathy, magnesium deficiency, hyperparathyroidism, diuretic use, peripheral vascular disease, rheumatoid arthritis, diabetes mellitus, and strenuous sports activities⁴.  In one study, 71% of patients with tendon disorders associated with fluoroquinolone use were over 60 years old and 20% were using steroids concomitantly.²  These two characteristics appear to be the strongest risk factors.

Information on how long the risk of tendon rupture persists after levofloxacin use is hard to find.   One source stated that the risk of tendon rupture could occur as early as a few hours to as late as 6 months after the initial dose, with most occurring at the 2-week mark⁴.

In summary, the multiple uses of levofloxacin and concomitant use of steroids increased your risk of tendon rupture.  In the future, use of an alternate antibiotic would be advisable.  If that is not possible, avoiding steroid use in conjunction with a fluoroquinolone would be recommended.  

Please see a prior article in on fluoroquinolones and tendon rupture for a broader overview.

Michael Krafczyk, MD
St. Luke’s Sports Medicine, Bethlehem, PA

References

1. Van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HM, Rowlands S, Stricker BH.  Increased risk of Achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids.  Arch Intern Med.  2003;163:1801-1807.

2. Van der Linden PD, Van Puijenbroek EP, Feenstra J, In ‘T Veld BA, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH.  Tendon disorders attributed to fluoroquinolones:  A study on 42 spontaneous reports in the period 1988 to 1998.  Arthritis Rheum.  2001 Jun;45(3):235-239.

3. Liu HH.  Safety profile of the fluoroquinolones: focus on levofloxacin.  Drug Saf. 2010 May 1;33(5):353-69.

4. Gold L, Igra H.  Levofloxacin-induced tendon rupture:  A case report and review of the literature.  J Am Board Fam Pract.  2003;16:458-460.

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date: December 9, 2010