Tendonitis or Achilles tendon rupture? Check your medications and DNA.
Tendonitis is a painful condition occurring in various body parts, such as the shoulder, bicep, elbow, hand, wrist, thumb, calf, knee, or ankle. It is often caused by excessive exercise and can be a common complication in people with arthritis. While less common, Achilles tendon rupture can happen to athletes and older adults. It is important to note that severe tendonitis, rotator cuff or Achilles tendon tears can also be associated with certain medications. If you’re experiencing any symptoms of tendonitis or have concerns about a potential rupture, consult your healthcare provider for a proper diagnosis and treatment.
Jeff’s story:
It all started when Jeff felt a sharp pain in his stomach. He went to the hospital and was diagnosed with acute appendicitis, where he was prescribed levofloxacin for two weeks. While taking this antibiotic, his stomach pain subsided in just a few days. By day seven, he felt pain in both Achilles tendons. After two weeks, he started to develop swelling in the tendons. Soon after, Jeff felt a sharp, painful snap in both Achilles’ tendons while changing trousers. Both tendons were ruptured completely at the mid-portion. Before this episode, Jeff had no health troubles that would explain the fragility of his Achilles tendons. During recovery, his physiotherapist commented that levofloxacin might be the culprit.
Imagine you were one of these people, simply taking a medication, even an antibiotic ear drop, and you experienced tendonitis or suffered a tendon rupture. The table below can help you learn which drugs to watch out for.
Drugs associated with a significantly increased risk of tendonitis, rotator cuff or Achilles tendon ruptures
Drug Class | Medication | Risk of tendonitis and tendon ruptures |
Antibiotics
Fluoroquinolones Cephalosporines |
levofloxacin (Levaquin)
ciprofloxacin (Cipro) cephalexin (Keflex, Biocef) |
1.2 – 2.5 times |
Antihypertensives
Renin-angiotensin II receptor antagonists |
azilsartan (Edarbi)
candesartan (Atacand) irbesartan (Avapro) losartan (Cozaar) olmesartan (Benicar) telmisartan (Micardis) |
> 7.5 times |
Statins
HMG-CoA reductase inhibitors |
atorvastatin (Lipitor)
rosuvastatin (Crestor) simvastatin (Zocor) |
|
Steroids
glucocorticoids |
prednisone (Deltasone, Rayos, Sterapred, Meticorten, Prednicot) | 1.5 – 6.5 times |
Bisphosphonates | alendronate (Fosamax) | |
Aromatase inhibitors | tamoxifen |
Important things to note:
Antibiotics
Fluoroquinolone antibiotics are most known for causing rotator cuff or Achilles tendon ruptures. Yet, many other drugs can increase the risk of this complication. Fluoroquinolone antibiotics are widely used for respiratory, gastrointestinal and urinary tract infections. These antibiotics kill multiple types of bacteria. While almost all drugs in this class have been associated with an elevated risk of tendon ruptures, levofloxacin (Levaquin) has the most replicated association, followed by ciprofloxacin. Moxifloxacin had a lower risk of tendon ruptures. In 2023, fluoroquinolone antibiotics were also linked to the risk of suicidal side-effects.
In 2019, the FDA issued a warning to doctors not to prescribe oral and IV formulations of fluoroquinolone antibiotics for patients with Marfan or Ehlers-Danlos syndrome who have or are at risk of an aortic aneurysm. This warning applies to patients with peripheral atherosclerotic vascular diseases, hypertension, and older adults. The shared link between the risk of aortic aneurysm and tendon rupture is related to genetic, condition or age-related weakening of connective tissues. Topical fluoroquinolone antibiotics in creams pose lower risks and can be used, but systemic use should be avoided unless no other treatments are available.
Common fluoroquinolone antibiotics:
- Avelox
- Baxdela
- Cipro
- Ciprofloxacin
- Delafloxacin
- Factive
- Floxin
- Gemifloxacin
- Levaquin
- Levofloxacin
- Moxifloxacin
- Norfloxacin
- Noroxin
- Ofloxacin
- ProQuin XR
Other antibiotics, such as cephalexin (Keflex, Biocef), can also increase the risk of tendonitis and tendon ruptures. If you take these antibiotics and experience tenderness or pain in your joints or muscles, you should avoid strenuous exercise and be careful in your daily activities to prevent falls or strains. If the pain becomes more severe, consult your doctor and pharmacists to check if you can switch to another antibiotic; do not stop antibiotics on your own.
Analyses of medical records indicate that other factors contribute to the risk of antibiotic-related tendon rupture. This problem was higher among women, increased with age (60+), and co-treatment with steroids.
However, it’s not just antibiotics:
Steroids
Glucocorticoids treat various inflammatory and autoimmune diseases, including severe asthma, eczema and neurological conditions. Prednisone and other steroids pose a low to moderate risk of tendonitis on their own, but combined with other high-risk drugs, they can increase the likelihood.
Arthritis & anti-inflammatory medications
A weakening of the tendons and connections to bones causes joint and tendon inflammation. While arthritis drugs, including Humira, methotrexate, ibuprofen and other NSAIDs, aim to reduce pain and other symptoms, these drugs also increase the likelihood of ruptures. People who have chronic arthritis and are taking multiple anti-inflammatory medications have a higher rate of tendon ruptures, possibly because they feel less pain during physical activities despite weakened ligaments. However, the cause-effect for these drugs with the risk of these complications is not established.
Heart medications
Older adults taking blood pressure and cholesterol-lowering medications can also be at risk of tendon inflammation and ruptures. This risk of statin-induced joint pain is well established and is strongly affected by your DNA. Genetic variations can affect the metabolism of statins, determine the blood levels of these drugs, and the risk of side effects. Statins have a broad anti-inflammatory impact that not only reduces the risk of heart disease but also reduces cancer occurrence.
Blood pressure-lowering medications have also been implicated in an increased risk of Achilles tendon ruptures. Inherently reduced metabolism of antihypertensives can lead to drug buildup in the blood, dizziness and loss of balance. A consequence of this is that a fall can result in tendon ruptures and bone fractures.
Similarly, antidepressants and opioid painkillers can cause dizziness and loss of balance. These drugs are considered higher risk, particularly in older individuals. Liver function and drug metabolism decline with age; thus, the risk of falls progressively increases.
Did you know? Genetics can impact your risk of tendon inflammation and rupture.
Variations in the MMP3 gene (rs679620, rs3025058) and the COL5A1 gene (rs679620) have been associated with an increased risk of tendon inflammation and rupture. While these genetic predisposition factors are important, the risk of tendonitis and tendon ruptures can also be impacted by medications. Genetics also plays a crucial role in drug metabolism and complications.
DNA testing for drug response, also known as pharmacogenetics, can reveal your inherited drug metabolic profile. This information can help your pharmacist and doctor understand which medications pose a higher risk of side effects for you. With your custom pharmacogenetic test results, your doctor would be able to optimize drug doses or select an alternative, safer treatment.
With pharmacogenetics-based medication management, people, especially older individuals, experience fewer medication-induced side effects and are less likely to visit emergency departments and be admitted to the hospital.
Summary
- If you have arthritis or other conditions that increase the likelihood of tendon problems, you should be cautious when starting a new antibiotic or another medication that may increase your risk of injury.
- If you already suffer from tendonitis or have had a significant tendon injury, a pharmacogenetic test and medication review with a clinical pharmacist can help assess whether reduced drug metabolism or a drug-drug interaction could have increased your risk of this complication.
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ORDER NOWSelected references
FDA Warning About Fluoroquinolones and Risk of Aortic Ruptures or Tears
https://www.ehealthme.com/condition/tendonitis/
Nyyssönen T et al., Drug treatments associated with Achilles tendon rupture. A case-control study involving 1118 Achilles tendon ruptures Scand J Med Sci Sports. 2018 Dec;28(12):2625-2629.
Morales DR 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. 2019 Feb;39(2):205-213.
Baik S et al., Association between tendon ruptures and use of fluoroquinolone, and other oral antibiotics: a 10-year retrospective study of 1 million US senior Medicare beneficiaries. BMJ Open. 2020 Dec 21;10(12):e034844.
Guo R et al., Association between matrix metalloproteinase-3 gene polymorphisms and tendon-ligament injuries: evidence from a meta-analysis BMC Sports Sci Med Rehabil. 2022 Feb 16;14(1):26.
Karsten Knobloch Drug-Induced Tendon Disorders Adv Exp Med Biol. 2016;920:229-38.