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Curbside Consult Case for July

 
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Curbside Consult Case for July - July 22, 2008 4:04:26 AM   
Dr.Wagner


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All the information is given in this paragraph, no questions can be asked.


A 23 year old female basketball star hobbles off the court.  She has injured her ankle at some point while going for a rebound.  Prior to this, she has never suffered an ankle injury or lower extremity fractures.  She has significant pain over her achilles tendon, otherwise normal exam.  Past medical history is significant for asthma, a mitral valve prolapse, dental surgery for a traumatic tooth avulsion, and chronic UTI's (of which she is currently being treated).  Family history is significant for acute MI, COPD, and schizoaffective disorder.
Her current medications are Advair, albuterol, cipro, zyprexa and xanax.
What may be the underlying cause that may have led to her injury?


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RE: Curbside Consult Case for July - July 22, 2008 11:59:46 AM   
Sebastian Asselbergs

 

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Achilles tendon tear secondary to cipro use?

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RE: Curbside Consult Case for July - July 22, 2008 12:17:18 PM   
KAK

 

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Ditto

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RE: Curbside Consult Case for July - July 22, 2008 5:10:19 PM   
annpsu25

 

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There are a few studies out that I have researched for one of my clinical affliations.  Some patients with achilles tendonitis, rupture etc. have taken an antibiotic duting the injury, or just prior.  I agree with the other posts.

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RE: Curbside Consult Case for July - July 22, 2008 6:33:56 PM   
buckeye

 

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These sound like reasonable ideas based on the information given. Was she taking a fluoroquinilone antibiotic for her chronic UTIs?

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RE: Curbside Consult Case for July - July 22, 2008 7:31:23 PM   
bonez

 

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I concur that tendon pathology secondary to antibiotic or the steroid use would need to be ruled out. We would also be aware of bone path for some of the same reasons.

< Message edited by bonez -- July 22, 2008 7:35:50 PM >

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RE: Curbside Consult Case for July - July 22, 2008 10:50:18 PM   
jma

 

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I would say the CIPRO and/or the steroid use may have contributed to her ailments.

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RE: Curbside Consult Case for July - July 23, 2008 1:46:42 PM   
buckeye

 

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Oops - I did not  read the medication list. Sorry.

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RE: Curbside Consult Case for July - July 23, 2008 3:05:03 PM   
USAPT

 

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I'm going to take another route with this, just to be different....

Since she already running around, her HR and Bp are elevated, she becomes SOB, dizzy and loses her proprioceptive sense upon landing...but why? Is she having a drug interaction between the Cipro and Zyprexa or did she take a 'hit' off her inhaler and given the already increased HR and the MVP, did the albuterol increase her HR too much causing her to become disoriented with her landing affecting her achilles??

Now, I'm obviously no MD and the other responses seem more likely but what the heck.

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RE: Curbside Consult Case for July - July 23, 2008 3:19:49 PM   
USAPT

 

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Another thought..

A pt with MVP has increased connective tissue and if the chordae tendineae in the heart can weaken secondary to excessive GAG formation and loose collagen, then why can't the achilles tendon weaken as well??

yes, I researched the MVP b/c I have a pt with it and I'm a nerd for learning!! 

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RE: Curbside Consult Case for July - July 25, 2008 1:09:57 AM   
Dr.Wagner


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The FDA has told manufacturers to strengthen the existing wording on fluoroquinolones' labeling with a boxed warning and to provide a medication guide for patients to highlight the increased risk for tendon rupture and tendinitis. (The warnings do not apply to fluoroquinolones used in eardrops or eyedrops.)

Patients on fluoroquinolones should be told not to exercise vigorously while on the medication.  While this patient is not in the "at risk group" (elderly or those on chronic ORAL steroids), it is a scenerio that is well within reason.

Cipro is, of course, a fluoroquinolone. 
I thought this case would be somewhat timely as these developments are just weeks old.


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RE: Curbside Consult Case for July - July 25, 2008 6:38:50 PM   
buckeye

 

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Based on this information, shouldn't we screen our patients for recent antibiotic use (specifically the flurorquinolones) especially if we are seeing them for Achilles relates problems? I do not recall any research or studies about other tendons being affected.

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RE: Curbside Consult Case for July - July 28, 2008 1:13:37 AM   
Dr.Wagner


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Seems reasonable.


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RE: Curbside Consult Case for July - July 28, 2008 3:44:39 PM   
jma

 

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Getting medications used or taken in the past is part of our evaluation and knowing at least some of the fluoroquinolones, (ex. Cipro) can be helpful.

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RE: Curbside Consult Case for July - July 28, 2008 7:49:24 PM   
buckeye

 

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Is there any research available to let us know when it is 'safe' for people on fluoroquinolones to begin exercise? I posed a similar question about a year ago and nobody offered any response.

Since there is evidence of this type of antibiotic increasing the risk of tendinopathy or rupture, if we are seeing patients with tendinopathy who are taking or recently completed a dose of a fluoroquinolone - shouldn't we have some caution with exercise? One of the treatments of choice for Achilles tendinopathy is eccentric loading, an exercise that puts much stress on the tendon. Is a gradual progression with Total Gym over many weeks the best course? How soon can single leg eccentric calf loading be done safely? In this case, it is difficult to go with how the patient feels because thses exercises are typically painful - also, Achilles tendon ruptures from the fluoroquinlones can be spontaneous with fairly benign activity.

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RE: Curbside Consult Case for July - July 28, 2008 11:54:51 PM   
SJBird55

 

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buckeye... I contacted the pharm company because I had a patient a couple months ago attend therapy with a referral for "knee pain."  It was all related to Fluoroquinolones - the PCP and ortho missed that as a possibility.  Anyways... there is no current data on when exercise is safe.  Tendon ruptures occurred in the clinical trials anywhere from day 7 to some large number like over 100 after the initiation of the medication. 

buckeye, if you are interested, I can scan the relevant clinical trial information the pharm company faxed me.  The idiot at the company faxed 80 some pages and only maybe a dozen were applicable to the tendon rupture situation.  In my head, I had conservatively figured that it might take up to 6 months to have the pain side effects eliminated and the risk of rupture minimized.  I read that stuff maybe 8 weeks ago or so, so my memory isn't going to be accurate.

I do know from reading the clinical trials, folks 60+ in age probably shouldn't be prescribed that particular antibiotic - and in this area it is frequently prescribed for urinary tract infections.  The lady I saw had bilateral knee pain and bilateral shoulder pain and she was 63.  Her symptoms began 5-8 days after starting one of the meds.... she was on that for 30 days and then she was prescribed a different med in the same family - so she was on the darn antibiotics for 52 days!  No physician took her off the med even with her complaints of pain.

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RE: Curbside Consult Case for July - July 29, 2008 12:50:39 AM   
Sebastian Asselbergs

 

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Good info, SJ - Thanks! Maybe you could post the article titles and let the individuals find the stuff?

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RE: Curbside Consult Case for July - July 30, 2008 12:47:59 AM   
Dr.Wagner


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Well there is no reason someone 60+ shouldn't be prescribed the medication based upon age alone.  There are alot of resistant strains of E.Coli found in urine, so I do not prescribe it for UTI's.  But, it is quite good for pneumonia etc.  In fact, one could argue this class is OVERUSED and likely the most popular antibiotic nationally for CAP. 


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RE: Curbside Consult Case for July - July 30, 2008 1:23:34 AM   
SJBird55

 

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Can't post it, Bas.  It was all faxed to me and it was the clinical trials.  I'm not sure how to get the information any other way.  The manufacturing company sent it to me at my request.  When I searched online to figure out the side effects, timing of side effects and length the side effects could last, I could only come up with the label inserts - not the details of the clinical trials.  That was the reason I contacted the manufacturer.

Wags, there is a perfectly good reason the flouro whatever class of antibiotics should not be used for those 60+ in age - the clinical trials haven't subgrouped this age group well enough.  It isn't supported for pediatrics either.  When I contacted the pharmaceutical company about levaquin (or however you spell it), within the 80 some pages faxed to me, the written documentation faxed to me supported that the effect on older adults isn't known as well. 

July 2008 FDA labeling change:  http://www.fda.gov/medwatch/safety/2008/Apr_PI/Levaquin_PPI.pdf 

< Message edited by SJBird55 -- July 30, 2008 1:42:09 AM >

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RE: Curbside Consult Case for July - July 30, 2008 2:51:53 AM   
Dr.Wagner


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Yep, the quinolones aren't approved for peds...but like stated previously, used ad-nauseum for geriatrics, primarily for CAP (community acquired pneumonia), and since this disease is particularly deadly in those considered "elderly", quinolone (levaquin, avelox) therapy is considered the standard for monotherapy.  I personally use dual therapy with a macrolide and cephalosporin to avoid resistance.  Those are standards set by ACCP. 


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