Avoiding Achilles tendon ruptures in the elderly - Literature Monitor
Clinician Reviews, Oct, 2003

It has now been confirmed that quinolones, the most frequently prescribed antibacterial agents, increase the risk of Achilles tendon rupture in elderly patients, according to van der Linden et al reporting in the Archives of Internal Medicine. Among this group of broadspectrum antibiotics, ofloxacin conferred the highest risk. This increase was particularly notable among elderly patients who also used oral corticosteroids.

Data were culled from a computerized medical information database of eight million patients ages 18 to 95 in the United Kingdom. Cases were identified among patients with a first-time occurrence of Achilles tendon rupture not due to direct major trauma. Subjects' use of oral or parenteral quinolones was categorized as follows:

* Current exposure (ie, diagnosis of Achilles tendon rupture was given between the start of quinolone treatment and 30 days after the course of treatment).

* Recent exposure (no current exposure and course of quinolone treatment ended less than 180 days before diagnosis).

* Past exposure (patient was not currently or recently exposed, and course of quinolone treatment ended less than 18 months before diagnosis).

* Nonexposure (no use of quinolones in the 18 months prior to Achilles tendon rupture diagnosis).

A total of 1,367 cases were included in the analysis. A group of 50,000 controls were randomly selected and used to adjust for confounding factors such as organ transplantation, end-stage renal failure, rheumatoid arthritis, and diabetes mellitus.

The odds ratios (ORs) for Achilles tendon rupture were 4.3, 2.4, and 1.4 for current exposure, recent exposure, and past exposure to quinolones, respectively, compared with nonexposure. Risk of Achilles tendon rupture was highest among patients ages 60 to 79 (OR, 6.4) and patients 80 or older (OR, 20.4) who used quinolones. Quinolone use and risk were associated in a dose-response manner. Concomitant use of quinolones and oral corticosteroids nearly tripled risk, compared with current quinolone exposure alone.

Although as many as 6% of Achilles tendon ruptures in persons older than 60 may be due to quinolone use, the researchers note, the incidence of the condition in the general population is low. "Nevertheless, prescribers should be aware of this risk and try to avoid the combination with oral corticosteroids," they suggest.

van der Linden PD, Sturkenboom MCIM, Herings RMC, et al. Increased risk of Achilles tendon, rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids Arch Intern Med. 2003;163: 1801-1807.

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Arch Intern Med. 2003;163:1801-1807.
Vol. 163 No. 15, August 11, 2003

Increased Risk of Achilles Tendon Rupture With Quinolone Antibacterial Use, Especially in Elderly Patients Taking Oral Corticosteroids
Paul D. van der Linden, PharmD; Miriam C. J. M. Sturkenboom, PhD; Ron M. C. Herings, PhD; Hubert M. G. Leufkens, PhD; Sam Rowlands, MD; Bruno H. Ch. Stricker, PhD

Background In several case reports, the occurrence of Achilles tendon rupture has been attributed to the use of quinolones, but the epidemiologic evidence for this association is scanty.

Methods We conducted a population-based case-control study in the General Practice Research Database in the United Kingdom during the period 1988 through 1998. Cases were defined as all persons who had a first-time recording of an Achilles tendon rupture, and who had at least 18 months of valid history before the index date. As a control group, we randomly sampled 50 000 patients with at least 18 months of valid history who were assigned a random date as index date.

Results We identified 1367 cases that met the inclusion criteria. The adjusted odds ratio (OR) for Achilles tendon rupture was 4.3 (95% confidence interval [CI], 2.4-7.8) for current exposure to quinolones, 2.4 (95% CI, 1.5-3.7) for recent exposure, and 1.4 (95% CI, 0.9-2.1) for past exposure. The OR of Achilles tendon rupture was 6.4 (95% CI, 3.0-13.7) in patients aged 60 to 79 years and 20.4 (95% CI, 4.6-90.1) in patients aged 80 years or older. In persons aged 60 years and older, the OR was 28.4 (95% CI, 7.0-115.3) for current exposure to ofloxacin, while the ORs were 3.6 (95% CI, 1.4-9.1) and 14.2 (95% CI, 1.6-128.6) for ciprofloxacin and norfloxacin, respectively. Approximately 2% to 6% of all Achilles tendon ruptures in people older than 60 years can be attributed to quinolones.

Conclusions Current exposure to quinolones increased the risk of Achilles tendon rupture. The risk is highest among elderly patients who were concomitantly treated with corticosteroids.

From the Pharmacoepidemiology Unit, Department of Epidemiology & Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands (Drs van der Linden, Sturkenboom, and Stricker); Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands (Drs van der Linden, Herings, and Leufkens); Epidemiology and Pharmacology Information Core, London, England (Dr Rowlands); and Drug Safety Unit, Inspectorate for Health Care, the Hague, the Netherlands (Dr Stricker). The authors have no relevant financial interest in this article.

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