Q. I’m 58 and in my 34th year as a T10 complete para. Over the years I’ve managed symptomatic UTIs with Cipro, and later with Levaquin, both of which wiped out the UTIs with no side effects. Fortunately, I haven’t had a UTI in over a year.
I’ve noticed a lot of buzz that suggests these antibiotics can cause tendon problems. I’ve seen articles, SCI forums and late-late-night TV ads asking variations on, “Have you taken a type of drug called fluoroquinolones and had a tendon rupture? If so, call ‘so-and-so’ attorneys at …” This got me thinking. Like many of my peers who have had SCI for decades, I was recently diagnosed with rotator cuff tears in my shoulder. I’m wondering if there is a connection with these drugs?
These antibiotics work great when I get a UTI. Are they dangerous to my tendons? And if so, for how long? Are the effects cumulative? And what are the options.
A. Chris, this is a topic that is frequently in the news. The FDA has issued “black box” warnings on these drugs — the strictest precautions it puts on prescription labeling. You should take these very seriously and discuss the risks and benefits with your physician. Here is a look at how the warnings came to be, along with a look at the reports in perspective and options to help avoid UTIs.
Fluoroquinolones — which include ciprofloxacin (Cipro), levofloxacin (Levaquin), Proquin XR, Ofloxacin, Noroxin, Moxifloxacin and Gemifloxacin — are a class of broad-spectrum antibiotics that were introduced in the ’80s and ’90s. They are great for infections in the bladder and kidneys, and testicular infections like epididymitis, because they target gram-negative bacteria, which are the most common bacterial culprits, says Dr. Michael Kennelly, director of urology at Carolinas Rehabilitation in Charlotte, North Carolina.
Millions of people take fluoroquinolones each year, and most find them effective with few, if any, problems. It is important to note that all medications, even aspirin, have the potential for serious side effects and fluoroquinolones are no exception. A PubMed search brings up journal articles that associate fluoroquinolones with tendon damage starting in the mid-’90s, and reports have become more frequent in subsequent years. So far, there have been no clinical studies that prove a cause-effect link, only anecdotal evidence.
The FDA keeps tabs on reports of side effects of drugs, and when enough reports of a side effect happen, they take action. In the case of fluoroquinolones and tendon damage, by 2008 enough reports had been logged — plus a petition and lawsuit by Public Citizen, a nonprofit consumer rights organization — that the FDA decreed a “black box” warning be added to fluoroquinolone drug labels, prescribing information and treatment guides. In 2016, the FDA issued further caution with an advisory suggesting that fluoroquinolones should not be used to treat uncomplicated urinary tract infections — as well as acute sinusitis and acute bronchitis — due to association with tendon pain and damage.
In 2018 the FDA issued yet another warning on fluoroquinolones, this time about the risk of ruptures or tears in the aorta. However, with aortal side effects, the risk is specific to people with a history of blockages or aneurysms of the aorta or other blood vessels, high blood pressure or certain genetic disorders that affect blood vessels and the elderly.
Since these reports of tendon injury weren’t made under controlled trials, there is no way to know if they are directly related to the drug, says Kennelly. “The FDA is saying, ‘even though we don’t know fluoroquinolones are a direct cause, there is enough substantial evidence in the reports of side effects that we need to look at this.’”
Risks, Rewards and Alternatives
For perspective on the risks, Dr. Jerome Stenehjem, medical director at Sharp Rehabilitation Center, searched on the medical site UpToDate.com and found the incidence of tendon pain associated with use of fluoroquinolones is about one per every 200 treatments. Tendon rupture is about one per 800 treatments. According to a 2012 study, fluoroquinolone-associated tendinitis “is more pronounced among elderly persons, non-obese persons, and individuals with concurrent use of glucocorticoids.” The Achilles tendon is what is injured in the majority of cases — and this is associated with running and jumping — but other tendons, including the rotator cuff can be affected.
Reports associate increased risk of tendon injury immediately following antibiotic use for up to five months, but Stenehjem thinks the risk drops off sharply after two months and decreases over time. A 2017 article in Infectious Diseases Consultant states that symptoms have an average onset of just nine to 13 days after the start of drug therapy.
Stenehjem also says that if you do need to take a course of a fluoroquinolone and notice pain in a tendon or joint, you should stop taking it and talk with your doctor right away, so you can be switched to a non-fluoroquinolone antibiotic. Then, take it easy so you don’t turn tendonitis into a rupture.
This brings us to ways to help avoid taking fluoroquinolones, starting with the basics of trying to avoid UTIs: drink plenty of water — enough to keep your urine in the clear-to-straw-color range — and make sure your bladder management system is fully draining your bladder.
People also report success in UTI avoidance by taking D-mannose capsules, which fight E. coli by “lubricating” the bladder walls, making them slippery so the bacteria can’t gain a stronghold. Cranberry capsules may help, but keep in mind that cranberry juice isn’t strong enough and can contain harmful sugar. The capsules decrease urine pH, making it more acidic, which creates a hostile environment for certain bacteria. Vitamin C also makes the urine acidic.
Another option for preventing recurring UTIs is to ask your doctor about using an antibiotic irrigant solution in your bladder. It’s also important to get a yearly urology check-up for kidney and bladder stones, which can cause recurrent UTI.
If you do get a UTI, it is important to use an antibiotic that targets the specific bacteria you have rather than a fluoroquinolone. This is done by submitting a urine sample to a lab at the first sign of infection. An option to have this done quicker is to see if your physician will supply you with some urine collection cups and a standing order at a lab for a urine culture so you can bring it in immediately. Unfortunately, it takes 48-72 hours to get results from a urine culture and sensitivity report to pinpoint the most direct and effective antibiotic.
While you wait for the results of your culture, you can get started on the antibiotic most likely to target the bacteria you have by asking your doctor to check the antibiogram for your area, which has data on bacteria susceptibility and resistance in a specific area the size of a clinic, hospital, or even a region, says Kennelly. Bacteria develop different resistances in different areas, and recent information from an antibiogram can stack the antibiotic deck in your favor.
“These days I think if physicians have their choice, they will say ‘Well, there has been enough bad press about fluoroquinolones that if we have an option, let’s try and steer away to something different if we can,’” says Kennelly. “However, for patients of mine that have a UTI and have used Cipro and it has worked and they’ve not had any problems, it is still a good option. But with the information that is out there, fluoroquinolones are no longer our reflex go-to antibiotics like they were 20 years ago when I was in training.”
• Bladder Irrigant Solutions for UTI Reduction, newmobility.com/2015/12/bladder-irrigant-solutions/
• FDA warning on fluoroquinolone and aorta damage, fda.gov/Drugs/DrugSafety/ucm628753.htm
• Minimizing the Risk of Tendon Injury With Fluoroquinolone Use, consultant360.com/articles/minimizing-risk-tendon-injury-associated-fluoroquinolone-use
• WebMD: FDA Warning: Cipro May Rupture Tendons, webmd.com//osteoarthritis/news/20080708/fda-warning-cipro-may-rupture-tendons