PART
XVIII:
TENDONS
AND CARTILAGES
131.THE ACHILLES IS NOT THE MOST FREQUENTLY AFFECTED TENDON
Most young doctors
know, because it is part of the current medical education, that
fluoroquinolones may cause tendonitis, although rarely they think. For all floxed
persons, it is extremely well known that quinolones destroy (necrose) tendons;
not only in susceptible individuals but also in every human that takes them.
And all tendons of the body are equally affected. By now, you have already
learned that thousands of reports of ruptures plague the medical literature and
the real clinical experience of many doctors and that those reported ruptures
are less than the tip of the iceberg because nearly all ruptures take place
months after completing the treatment, and nobody links them with the
antibiotic. To become part of the statistics of tendons ruptured by quinolones,
the rupture has to happen during the treatment, and without any other causative
factor, otherwise it is very difficult if not impossible to link the rupture to
the antibiotic. From the different studies done on the efficacy of reporting
these kinds of injuries, it could be deducted that less than 5% of the ruptures
of the tendons happen during the actual treatment with the fluoroquinolone.
We all know that
some tendons become more painful than others, because in our personal physiques
some tendons have less irrigation than others or because we tend to use them
more than others because of our muscle balance and muscle activity.
So, for us the
floxed persons, it is equally critical to assess the situation of all of our
tendons, whether they are at the shoulder, hip, knee, ankle, wrist, fingers,
neck, jaw, back or wherever.
But our doctors are
grossly ignorant. In some countries they have been made to believe that the
only tendon affected is the Achilles, and only in very rare instances. There
are Eeuropean countries where the package insert only refers to the
tenotoxicity (tendon toxicity) saying that "if you feel pain in the
Achilles tendon, stop the treatment and consult your doctor". This seems
to imply that you shouldn't watch out for any other tendon pain. So if you
rupture your major shoulder tendons and become handicapped, do watch somewhere
else (and take more quinolones and get injured for life). This way of
explaining things in the package inserts also make doctors prone to think that
if the drug only affects the Achilles tendon, that has to be a very odd
reaction and odd reactions afflict only rare people. Some doctors with
extremely great reputations in their fields, that match the cost of their
bills, very used to prescribing quinolones, have been asked by their patients
about "this sudden pain in my achilles area" while taking cipro, for
instance, and their doctors have refused any possibility of the pain being
caused by cipro because "that is an extremely rare event that cannot be
your case" and because "if we paid attention to all warnings in the
package inserts we would not take any medicine at all". There is no need
to mention that some of those floxed persons developed extremely severe
floxings soon after their courses of cipro ended. This demonstrates once again
that a more honest approach to the toxicity of quinolones is warranted.
A honest
description of the tenotoxicity of the quinolones in the package inserts should
be described crudely like it is, as it has been demonstrated in hundreds of
medical experiments, for instance like this:
"During the post marketing surveillance of this medicine,
relatively unexpected tendinitis and ruptures of major and minor tendons have
been reported in all kind of people. Ruptures reach disproportionate
frequencies of up to 50% in persons that take this antibiotic with
corticosteroids. In young, healthy and active people tendinitis becomes
symptomatic in 5% of persons for low dose and short treatments, and in 100% of
people with the highest doses approved and/or long treatments. The injuries of
the tendons may appear months or a few years after exposure to the drug and
tend to heal very slowly, and in many cases they become chronic or permanent.
The injuries of the tendons are cumulative, so keep a record of the total
amount of quinolones ingested in the life of the patient".
Finally, look at
the distribution of the incidence of tendinitis of the foot-ankle provided in
the next chart, and see that the achilles tendon does not lead the league of
most affected tendons, very much to the contrary to the common (common in this
context means 'ignorant') doctor's belief.
If you have read
the account about tendinitis caused by quinolones compiled in this report, and
browsed through the medical literature, you will wonder why the
figure 23
first question that
a doctor asks his/her patients complaining of tendinitis is not whether they have taken quinolones in the
past months. There are very few professions that are so indulgent with such a
sheer incompetence.
Figure 17 shows how
sedentary people are less symptomatic than active people in terms of average
number of tendons noticeably affected.
When you suffer an
intense
figure 24
intoxication by
quinolones, there is an impact on virtually all the tendons of the body. Some
will become more symptomatic and even will prostrate you. You can become
temporarily crippled for some months. You can find hard to get up, to undress
yourself, to walk small stretches at home, to lift things or to perform the
minutest domestic tasks.
More than half of
the floxed persons most severely hit have reported resilient tendinitis in at
least 6 places, some of which “migrated” along the body with time. We mean by
“migration” in this context that some of the tendons more symptomatic vary
along the timeline.
Some of the damage
on the tendons is irreversible. Obviously, tendon necrosis and degeneration is
the real pathology caused by quinolones. Symptoms are much less pronounced in
sedentary people for obvious reasons.
132.THE PERSISTENT TENDINITIS
Many floxed persons experience a recovery after some
months or a few years of suffering. Some even come to believe that they feel
pretty much normal. And then, when the nightmare seems over, a few months after
the last bothering symptoms settled down, an intense bout of tendinitis and
muscle pain develops, both in areas where previously tendinitis were present,
and also in many new ones.
These new bouts of tendinitis and myopathies tend to
last a few more months or years, depending on the severity of the renewed
reaction.
If the healing has taken place in less than 18 months,
then the bonus tendinitis can last for another 12 months or more. The intensity
of the new tendinitis is comparable with the tendinitis at the onset.
If the time elapsed since the onset until a decent
improvement is longer that 3 or 4 years, this
figure 25
rebounding
and lingering tendinitis can last another 2 or 3 additional years, causing a
great intensity of pains and limitations.
In many cases these tendinitis are bursitis or
insertional tendinitis, but stenosing tendinitis and fluid accumulation is also
observed.
This sort of bonus tendinitis has been detected in
more than 80% of intermediate and severe floxed persons that met all this
criteria:
-tendinitis at the beginning of the intoxication
-active people
Look to this report by some french researchers.
[EPICONDYLITIS
INDUCED BY FLUOROQUINOLONES IN ATHLETES. APROPOS OF 2 CASES]
Le Huec JC,
et al. Universite de Bordeaux II.
Epicondylitis
occurred in two leisure athletes who were taking fluoroquinolones. No similar
cases have been reported in the literature. In both cases, pain occurred early
after initiating drug therapy. Pain was intense and was not controlled by usual
care. Echography demonstrated major inflammatory injuries with pseudo-necrosis.
Magnetic resonance imaging confirmed the injuries and gave evidence of
infraclinical injuries of the adjacent tendons. Surgical disinsertion of the
epicondyles with biopsy was indicated due to the persistent pain. Histological
examination revealed unspecific injuries of hyalin degeneration and a few giant
cells in one case. Pain disappeared after surgery and the patients were able to
return to their work, but neither was able to continue his sports activity.
Injuries of the Achilles tendon have been observed in patients taking
fluoroquinolone and the two cases reported here confirm the possibility of
other localizations. Care must therefore be taken when prescribing these
antibiotics in patients at risk (dialysis patients, those on corticosteroids, high-performance
athletes).
The report says that no similar cases have been reported in the
literature. Well, we are not "literature" after all, but we have
recorded more than 90 epicondylitis induced by fluoroquinolones during the life
of the present report. We also confirm that injuries can take place at
localizations other than the Achilles tendons.
133. QUINOLONES AND FORGING, TWO INSEPARABLE
COMPANIONS
Don’t you think that it is quite strange that an
antibiotic is toxic only for the achilles tendons and only to special (flawed)
persons? That is the firm belief of most doctors. After more than 20 years of
appalling evidence things have changed very little.
Fluoroquinolones have been tested in many mammals. No
mammal has been found whose tendons remain undamaged after a treatment with
fluoroquinolones. All animals tested in hundreds of trials suffered tendon and
cartilage destruction. Still today, after 20 years of continuous research, some
manufacturers are looking for a mammal that can withstand a quinolone treatment
without getting their cartilages and tendons destroyed. You can make a brief
search on the veterinarian literature and will see how fluoroquinolones destroy
animal joints (cats, dogs, horses....). It is a very widespread fact much more
honestly treated and admitted among veterinarians, than its counterpart for
humans. In other words, veterinarians have openly researched quinolone-induced
tendinitis and osteoarthritis in animals, which is widely acknowledged now.
They have instated some restrictions for their use, and have also developed
some protocols for treating floxed horses, cats, dogs and other species.
All in vitro tests with human specimens show tendon
and cartilage destruction. But, wonder of wonders the manufacturers have
convinced all doctors that cartilage and tendons of humans are different, and
that tendon damage caused by quinolone therapy is an extremely rare event. For
manufacturers, cartilage toxicity in humans has not yet been proven. For them,
the thousands of injuries in the cartilages of victims of quinolones are caused
by anything else or an extremely rare event of people already prone to it.
To forge simple mathematical calculations is easy.
They divide the hundreds of millions of prescriptions of quinolones by the
number of medically recorded ruptures of tendons attributed to them and
conclude that the risk of rupturing a tendon is very low, so low in fact that
it is similar to the risk of a person rupturing a tendon that has never taken a
quinolone in his/her life. But the truth is different. The real ratio of people
with injuries to the tendons for long and high dose treatments is 100%, so
there is a clear toxicity. The injuries of the tendons of people that have
taken small doses of quinolones are minimal and asymptomatic, so they do not
appear in the statistics. And most tendon ruptures, perhaps 95% or more caused
by quinolones are not linked to the antibiotic because they take place many
months after ingesting the medicine and they are not the achilles tendon.
When immature animals are tested, the worst injuries
are observed. Yet the manufacturers are fighting hard to get their quinolones
approved for children, whereas currently they are not advised for people less
than 18 years of age.
No matter how sad the immoral and greedy frivolity of
the manufacturers may look to the eyes of decent people, the real tragedy is
that tendon toxicity (tenotoxicity) and cartilage toxicity (chondrotoxicity)
are guaranteed sequela of all quinolone treatments. When you take a quinolone antibiotic,
all the tendons and cartilages of your body are exposed to this substance, and
invariably get damaged. The damage, ranging from undetectable to a complete
rupture, will show up in the months to come, and will depend on many factors,
that have been discussed throughout this report.
Do not forget that the damage is cumulative. So, the
more quinolones you take over the years, the deeper and more extensive damage
they cause.
In the reference section, there are many works listed
on quinolone tenotoxicity and chondrotoxicity. Sometimes it is hard to find the
excerpts of the reports. Here we reproduced some passages of some of them.
QUINOLONES
AND TENDON RUPTURES, FROM SOUTHERN MEDICAL JOURNAL
J.
Michael Casparian, MD, et al, Department of Medicine, University of Kansas Medical Center, Kansas.
We
report two cases of tendon rupture associated with ciprofloxacin that highlight
unusual features of this association. One case involves a complete Achilles
tendon rupture occurring 6 months after
the medication had been discontinued. In the second case, a partial rupture
of the subscapularis tendon of the right shoulder occurred during mild stretching exercises. These cases provide insights into
the broad nature of tendon ruptures that can be associated with
fluoroquinolones. Because these antimicrobials are used commonly, clinicians
need to be aware of the potential adverse effects that fluoroquinolones may
have on tendons.
Case
Case
We know of at least 4 physicians that have had
ruptures of tendons or suffered very severe tendinitis requiring crutches,
caused by quinolones. Three of them did not report it to the MedWatch drug
reaction reporting system.
Transplant recipients have an extremely high ratio of
rupture of tendons if they take quinolones, not from the transplant but
probably because they took steroids at the same time:
ACHILLES
TENDON DISEASE IN LUNG TRANSPLANT RECIPIENTS: ASSOCIATION WITH CIPROFLOXACIN
P.N. Chhajed, et al. Heart
Lung Transplant Unit, St. Vincent's Hospital,
Achilles
tendonitis or rupture are uncommon complications following the use of
fluoroquinolones, with a reported incidence in the general population of 0.4%.
The aims of the current study were to determine the incidence of Achilles
tendon disease in lung transplant recipients and to identify risk factors.
Only
the use of ciprofloxacin was significantly associated with achilles tendon
disease. Age, sex, underlying disease necessitating transplantation, serum
creatinine and cyclosporine levels were not associated with achilles tendon
disease. The association between ciprofloxacin and achilles tendon disease was
not dose related. Of the 72 lung transplant recipients who had received
ciprofloxacin, 20 (28%) developed achilles tendon disease (tendonitis 15,
rupture five). In patients receiving ciprofloxacin, there was no association
between the mean cumulative dose of prednisolone and achilles tendon disease.
Tendon rupture occurred with a lower ciprofloxacin dosage than tendonitis and
the mean recovery duration was significantly longer.
To
conclude, lung transplant recipients receiving ciprofloxacin are at significant
risk of developing Achilles tendon disease. The association between
ciprofloxacin and Achilles tendon disease appears to be idiosyncratic rather
than dose-related.
Comments: It seems quite odd that according to the
manufacturers the general population develop 0.4% cases of tendonitis after a
treatment of ciprofloxacin and according to a detailed follow up in a hospital
lung transplant recipients develop 28%. One big difference is the prednisolone
that the transplant recipients took that the general population did not. But on
the other hand, the transplant recipients were physically inactive in general,
so their risk of rupturing a tendon was diminished in respect to the general
population.
If the general population were prescribed the same
doses and length of treatment of ciprofloxacin as the lung recipients, the
occurrence of tendinitis would be roughly the same 28%. If, in addition, those
patients started an active life, the ratio of tendinitis reported would be
100%. And if the dose was somewhat higher, the occurrence of tendinits would also
be 100%, irrespectively of the activity level of the patient, as in table 3 of
this report.
134. TENDIFLOXITIS
In summary, the main facts to remember about the
toxicity of quinolones on the tendons and cartilages are:
1. The injuries are guaranteed, it is a class effect of
these medicines.
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