Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis

Eur J Clin Pharmacol. 2019 Oct;75(10):1431-1443. doi: 10.1007/s00228-019-02713-1. Epub 2019 Jul 4.


Purpose: Tendinopathy is a known adverse reaction associated to fluoroquinolones, but a meta-analysis was not yet published. The aim of this study was to conduct a systematic review and a meta-analysis of the scientific evidence evaluating the risk of tendon injury associated with fluoroquinolones.

Methods: A literature search was conducted to identify observational studies which reported results on the risk of Achilles tendon rupture (ATR), risk of Achilles tendinitis (AT), or risk of any tendon disorders (ATD). A meta-analysis was performed by pooling odds ratios (ORs) with their 95% confidence intervals (CIs).

Results: Fifteen studies were included in the meta-analysis. Treatment with fluoroquinolones was associated with an increased risk of ATR (OR 2.52 (95% CI 1.81-3.52), p < 0.001, I2 = 76.7%), an increased risk of AT (OR 3.95 (95% CI 3.11-5.01), p < 0.001, I2 = 0%), and increased risk of ATD (OR 1.98 (95% CI 1.62-2.43), p < 0.001, I2 = 84.5%). The initial risk estimates remained statistically significant among patients aged ≥ 60 years old. Risk estimates did not significantly change after depending on the concomitant use of corticosteroids or studies methodological quality assessment. The analysis according to the type of fluoroquinolones was only possible for ATR, which were ofloxacin and norfloxacin were found to increase the risk of this outcome, but not ciprofloxacin and levofloxacin.

Conclusions: The results of this meta-analysis confirm the risk of tendon injuries associated with fluoroquinolones. Older age and concomitant use of corticosteroids seem to be additional risk factors for tendinopathy.

Keywords: Fluoroquinolones; Meta-analysis; Pharmacovigilance; Risk assessment; Tendinopathy.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Fluoroquinolones / adverse effects*
  • Humans
  • Observational Studies as Topic
  • Risk Factors
  • Tendon Injuries / chemically induced*
  • Tendon Injuries / epidemiology


  • Fluoroquinolones