Cipro and Climbing

I have tonsillitis. Yeah, gross. Doctor prescribed me Cipro (antibiotic). But this stuff has a pretty serious Black Box Warning that says it can lead to some crazy tendon issues (like legit ruptured tendons), joint pain, permanent nerve damage, etc. So now I'm freaked out. I haven't started taking it yet. Doctor said something like, "don't go skiing or anything...". I told him I'm a climber. But I don't think he knows just how much stress that puts on your tendons, joints, etc. The warning label says tendon injuries can happen even up to 6-9 months later.

Has anybody here ever taken this antibiotic? Did ya'll die or what? Did your tendons all explode? You turn into a plate of spaghetti? Gimme the details, please.

That's an interesting question.

As an ER doctor I only really get concerned with cipro and the older population whose tendons are generally weaker with age. As a climber, spontaneous tendon rupture is going to be unlikely since your tendons are strong but shit, I would wait until you are done with the antibiotic to climb because who wants to risk that. My guess is you would still be totally fine but you are the one who needs to calculate the risks and benefits. I wouldn't wait 6-9 months AT ALL though. 1) it's a rare (but obviously) serious complication and 2) less common in young, healthy patients.

A quick review of PubMed: risk factors associated with FQ-induced tendon disorders include age greater than 60 years, corticosteroid therapy, renal failure, diabetes mellitus, and a history of musculoskeletal disorders.

(FQ - fluoroquinolone i.e. cipro)

As an RN who reviews CDC bulletins daily regarding cipro and other medical issues I would say definitely ask your clinician for another antibiotic, of which there are several that will work for tonsillitis. Recently CDC upgraded the warning for cipro. It used to be contraindicated just for those over 65. Research has shown that the side effects are quite long lasting and can be damaging to nerves and tendons in the long run..not just those first few months. There's usually no need to take cipro for tonsillitis unless you are allergic to many different antibiotics.

FourT6and2 wrote:I have tonsillitis. Yeah, gross. Doctor prescribed me Cipro (antibiotic). But this stuff has a pretty serious Black Box Warning that says it can lead to some crazy tendon issues (like legit ruptured tendons), joint pain, permanent nerve damage, etc. So now I'm freaked out. I haven't started taking it yet. Doctor said something like, "don't go skiing or anything...". I told him I'm a climber. But I don't think he knows just how much stress that puts on your tendons, joints, etc. The warning label says tendon injuries can happen even up to 6-9 months later. Has anybody here ever taken this antibiotic? Did ya'll die or what? Did your tendons all explode? You turn into a plate of spaghetti? Gimme the details, please.

Hello there FourT6and2,

I am a pharmacist, I hope I can help. I can say that I likely have more experience with this drug than any individual patient (in that I have dispensed it hundreds of times to people) and I have never had any of my patients report these issues. Additionally, of my many friends and colleagues who are also pharmacists... I am not aware of any case of this actually occurring. That of course does not mean it won't, but the incidence seems to be quite low. There is data available on the incidence of tendonitis (tendon pain) and tendon rupture (tearing). Studies have found that the incidence of tendonitis is ~2.4 out of 10,000 and tendon rupture is ~1.2 out of 10,000 and the Achilles tendon is the tendon affected 95% of the time (see source 1 below). What this means is that if you were to take this medication 10,000 times for 10,000 cases of tonsillitis, you could expect tendon pain to occur ~2 of those times and more substantial tendon damage to occur ~1 time. ...Also for a comparison... some quick googling suggests that your risk of dying in a fatal automobile accident is ~1.12 out of 10,000 (similar to tendon rupture). (source 2)

The article goes on to discuss that there are usually multiple risk factors that precede any tendon issues. The risk seems to be higher for those with weaker tendons (older people; average age of 59) and if you are taking another medication called a corticosteroid (prednisone is an example) at a low dose for a long duration.

Then the event that does seem to "cause" the tendonitis/rupture is "excessive loading during strenuous exercise" (source 1). I'm not sure about your climbing style, but typically the forces my ankle experiences when approaching/climbing generally are very controlled and not "excessive" like in the case of a quick direction change (i.e. basketball) or as your doctor suggested -- skiing where your ankle could be subjected to tremendous force in the event of a fall. (Also, maybe down-climb if bouldering)

I realize that this does not give you a definitive answer, but then again, I would be cautious about anyone that does. All medicines (and herbal supplements for that matter) are poisonous and can cause harm. Your doctor and your pharmacist always try to weigh the costs/benefits of the treatment decisions they make with you. So, in the end it is up to you. The outcomes you are rightly concerned about are severe, but quite rare, especially if you do not have any of the other risk factors outlined above. Likewise, climbing -- theoretically -- may not be as strenuous on your larger tendons as say basketball, but there is always the concern of unexpected forces (hitting a ledge/ground). If you do decide that the risks outweigh the possible benefits for you... then please let your pharmacist or doctor know! There are other medications that could be prescribed that do not have the same "black box warnings" as the fluoroquinolones (cipro is in this family) and you have a right to have your choices respected.

Hope that is helpful, and that you begin feeling better soon. (of note, the medication could take ~2-5 days for you to feel it working... however, if you are feeling NO better after a week -- or worse -- please do get in touch with your doctor.

...Oh, and to address the other side effects I did not discuss... I expect they are even more rare than the tendon issues. We have been monitoring the use of this drug for a long time (first case of tendon rupture was 1988) ...and in all that time of monitoring it we only now have enough evidence to add the warnings about the other side effects you mentioned. (the drug information was changed 5/12/16 -- see source 3)

Lastly, shameless plug for pharmacists -- come talk to us! We want to help you and love answering questions :)

1. J Athl Train. 2014 May-Jun; 49(3): 422–427. doi: 10.4085/1062-6050-49.2.09
PMCID: PMC4080593. Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature

2. iii.org/fact-statistic/mort…

3. fda.gov/Safety/MedWatch/Saf… SafetyAlertsforHumanMedicalProducts/ucm513065.htm

I am not a medical professional at all.

However, I did take a few rounds of Cipro about 3 years back for a stubborn tonsillitis infection, which I ended up needing surgery to finally get rid of. About 1.5 years ago I took a serious sprain to my ankle while climbing. About 6mo after that I developed Achilles tendonosis. I don't know if the medication is at all related to my tendonosis, but I can say that this is my situation.

The achillies tendonosis sucks really bad for climbing, and for life in general. I'm finally seeing progress after about a year of being really strict with my lifestyle. I've literally spent thousands of dollars and hundreds of hours over the last year trying to fix this thing without surgery.

For climbing it particularly sucks because doubting a tendon on route has put me in pretty weird situations. For example, climbing a sketch variation so I don't have to smear as aggressively on my bad achillies. It also really sucks being on a multi day route wondering if the next day I'll be totally screwed because my tendon decided to stop cooperating overnight (never happened yet, knock on wood!). Basically, climbing is way less fun if you can't trust your body to not break!

I'd say that even if the chance is slim, why risk it.

Agree with what's said above and can only add that I have seen the tendon rupture from FQ's, but only once, and it was a young guy, mid 30's but did have severe circumstances surrounding it. However I wanted to mention that unless your doc did cultures, it's my experience that Cipro is a poor choice for tonsillitis.....again sans culture. If you are not penicillin allergic I would strongly recommend taking Augmentin, 875mg, 1 tab, twice a day for 10 days. It can depend on location too, many regions have their out resistance maps and some providers, but not all, have access to these and it may be that in your area Cipro is the best.

Wow, thanks for all the info folks!

Yes, my doc did a throat culture. Results were Pseudomonas Aeruginosa, which showed susceptibility to Cipro. The lab results show some other antibiotics as well. But it seems Cipro is the best first choice for that bacteria.

I will have to talk to my doctor again I guess.

FourT6and2 wrote:Wow, thanks for all the info folks! Yes, my doc did a throat culture. Results were Pseudomonas Aeruginosa, which showed susceptibility to Cipro. The lab results show some other antibiotics as well. But it seems Cipro is the best first choice for that bacteria. I will have to talk to my doctor again I guess.

That explains a lot, otherwise cipro did seem like a really odd choice. Speaking as an MD, I would definitely risk the cipro over Pseudomonas brewing in my body, that is a grouchy bug for sure. But just go ahead and call your doctor (no need for a visit in my opinion) and tell him/her about your tendon concerns and see if there's a good alternative. But if they say there isn't, compared to pseudomonas spreading to some other part of your body, go with the cipro.

I should say that this is also a beautiful example of why you need to be really careful of getting medical advice off of the Internet. There are a number of experienced people contributing to this thread, but we all lacked the key piece of information that your doctor had that made a rather odd treatment plan suddenly seem very sensible.

One of my relatives (healthy, about age 60) had a course of Cipro and within the next year needed distal bicep tendon repair on both arms. There's no way to say if the two are connected and it is only one case but it is something to think about.

There's no substitute for bacterial culture and antibiotic sensitivity testing. With that said I was prescribed Cipro but looked into it and found that TMS worked equally well so I took that instead.

And its called getting "Floxed".

Cipro sucks, I've taken it once or twice and it definitely messes with you....but I recall being fine as far as climbing on it. Maybe just take it a little easier than what you would normally do.

Talked to my uncle, who is a pharmacist and he basically gave me similar advice. Said the risk of complication from Cipro outweigh the risks of Pseudomonas. So... I'm gonna go for it. If y'all don't hear back from me soon, it's because all my tendons spontaneously launched out of my body.

FourT6and2 wrote:Talked to my uncle, who is a pharmacist and he basically gave me similar advice. Said the risk of complication from Cipro outweigh the risks of Pseudomonas. So... I'm gonna go for it. If y'all don't hear back from me soon, it's because all my tendons spontaneously launched out of my body.

I think maybe you meant pseudomonas risk outweighs cipro risk?

Optimistic wrote:I should say that this is also a beautiful example of why you need to be really careful of getting medical advice off of the Internet. There are a number of experienced people contributing to this thread, but we all lacked the key piece of information that your doctor had that made a rather odd treatment plan suddenly seem very sensible.

Yeah, my bad. I should have said culture indicated that specific bacteria.

Optimistic wrote: I think maybe you meant pseudomonas risk outweighs cipro risk?

Yeah, I think. haha. Basically he said go with the Cipro because it's worth the risk, when dealing with pseudomonas.

One of my friends, who was a 30 year old climber, ended up having sever physiological side effects from taking Cipro. He experienced debilitating tendinitis throughout his body, but no tendon rupture.

So Fourt6and2, how are you feeling?

Well I took a 5-day course of Cipro, as prescribed. I haven't noticed any side effects at all. But it also hasn't really helped my tonsillitis either! Saw an ENT the other day. She did another culture because the lab work my physician did doesn't give percentages for the antibiotic susceptibility. When my ENT heard I'm a climber she was upset my physician prescribed Cipro. She said she wouldn't recommend I take it again ever.

I'm probably going to have my tonsils out soon. But I have to kick this infection before the surgery. And apparently Pseudomonas is kinda rare to have in your throat and it's difficult to eradicate because it forms a bio-film.

So, long story short... my throat still hurts.

I went climbing at the gym yesterday, but took it easy.

Karl Henize wrote:One of my friends, who was a 30 year old climber, ended up having sever physiological side effects from taking Cipro. He experienced debilitating tendinitis throughout his body, but no tendon rupture.

Did those side effects happen immediately while on the Cipro, or some time later?

I think as for many antiobiotics, the most likely side effect would be diarrhea.