Could Entocort be weakening my tendons?

[jillian357]

Hi All!

I am battling a nasty case achilles tendonitis.....<sigh>

I was just reading online how some coristeriods can cause weakness in the tendons. I'm still taking my full dose (9mg) of Entocort every day, I can't seem to wean down without stomach flares despite watching my diet.

In your opinion, could the Entocort be contributing to my achilles problems? I realize I just ran a marathon three weeks ago, but this injury came on hard and fast after the race was over.

thanks!
Jill

[tex]

Hi Jill,

Sorry to hear about the tendonitis. As to whether or not your Entocort treatment may have contributed - that's a tough question. Yes, it might increase the risk, but that doesn't mean that it actually is, in your case, (after all, you just ran a marathon, a few weeks ago). It's well established, of course, that locally-applied corticosteroid treatment can cause such problems, but whether or not systemic treatment is a significant risk, has only recently been suggested.

Research with animals has shown that systemic use of corticosteroids can produce the same risks as localized treatment. The following quote comes from an article involving corticosteroid research with rabbits:

It is well established that local corticosteroid administration weakens tendons
and ligaments1. The effects of systemic corticosteroids on soft tissues are less
clearly established. In a previous study, short-term steroid administration
around tendon and ligament resulted in more failures to occur by bone
avulsion than by failure in the tendon substance during tensile loading2. We
found a similar tendency toward a change in failure site in animals that had
received systemic corticosteroids. It is well established that steroid
administration may result in osteoporosis. It is hypothesized that tissue with a
shorter turnover time (bone) weakens faster than tissue with a longer turnover
time (tendon, ligament) when corticosteroids are administered. This
differential collagen turnover may lead to a more profound decrease in
strength of bone compared with tendon, resulting in failure at the bone instead
of tendon.

Avulsion means tearing away, in case you're not familiar with the term. This research suggests that tendons are less likely to be affected than bone, or rather, it shows that it takes longer for significant effects to show up in tendons, compared with bone. That quote is from this PDF report:

http://www.ors.org/web/Transactions/45/0046.PDF

I've found a few references that show pretty clear evidence that systemic treatment with corticosteroids can indeed cause Achilles tendon issues. Here's one involving long-term use of prednisione, and I've seen others describing similar issues from inhaled corticosteroids:

http://www3.interscience.wiley.com/jour ... 1&SRETRY=0

This quote from that article may be more significant than meets the eye:

There have been several reports of bilateral Achilles tendon rupture associated with long-term corticosteroid use. It is likely that this entity is underdiagnosed because of a lack of awareness of this association by physicians.

The red emphasis is mine, of course. Basically, it appears to me that the risk may become significant with long-term use, but remember that these research reports are based on cases where systemic infusion of the corticosteroid was not restricted, so blood levels of the drug were always significant. IOW, these cases did not involve the use of enteric-coated delivery, (such as is used with Entocort EC). Therefore, the risk with Entocort EC, should be much lower. That said, since these are uncharted waters, IMO, long-term use of Entocort EC, (especially at the full dosage rate of 9mg per day), will most likely, at some point, incur a significant risk of damage to the Achilles tendon. That's not saying that it will happen to you, only that it might. The odds are anybody's guess.

I wish I had a more palatable opinion. Eventually, you'll need to make some hard choices regarding your treatment, and your running hobby. It might be a good time to start concentrating on trying to figure out why your diet is not working more effectively, since that's what's preventing you from being able to reduce your dose of Entocort EC. A lot of athletes take protein supplements. Are you by any chance taking any of those? Are you eating anything other than chicken, potatoes, and rice? If not, maybe you should try changing brands of chicken and/or rice. Are you taking any vitamins? If so, are they verified to be safe? Again, switching brands might be worth trying. Are you using any HRT, or birth control patches or pills? I don't mean to be nosy, but such hormone supplements can definitely cause problems in some cases.

Love,
Tex

[Rosie]

Steroids aren't the only drug that can cause tendon inflamation. The widely prescribed statins can too, and also cause muscle inflamation. I researched this when my husband started having lots of muscle aches and soreness after starting a statin. Are you taking statins by any chance? Here is what I found:

Statins, the most effective treatment for lowering cholesterol, are widely used and have been demonstrated to be safe in large clinical trials. Although side effects are usually mild, more severe side effects, especially musculoskeletal complications, have been reported. Tendon impairment has been reported anecdotally but has not been included in large-scale studies. A new study published in the March issue of Arthritis Care & Research found that, although rare, tendon complications are linked to the use of statins.

Led by Catherine Noblet, of Rouen University Hospital in Rouen Cedex, France, researchers identified 96 cases of tendon complications from the French Pharmacovigilance database between 1990 and 2005 that were attributed to statins. Tendon conditions included tendonitis and tendon rupture. Patient data retrieved from computer database were as follows: medical history, other medications they were taking (especially those known to increase statin concentrations), information about the onset, pattern and severity of their condition, and the dosage and type of statin they took.

The results showed that of the 4,597 side effects associated with statins, about two percent were attributed to tendon complications. Symptoms usually occurred within 8 months of beginning statin therapy. Most patients had tendonitis, but some also suffered ruptured tendons. The most common tendon affected was the Achilles tendon, with pain, swelling, warmth, and stiffness as the most common symptoms. Seventeen of the patients had symptoms severe enough to warrant hospitalization. The researchers were able to link the tendon problems to statin use based on the fact that the symptoms appeared after the statins were started, they improved when the statins were stopped and they recurred in all of the patients who restarted the therapy.

Rosie

[harvest_table]

Hi Jillian,

Sorry to hear about your tendon rupture and hope you heal quickly. After some quick research I found that usage of Quinolones (such as Zithromax) in conjunction with a medication like Entocort has been documented to sometimes cause tendon injuries. Google it.

I read an earlier post of yours that you were taking Zithromax, which is Quinolone medication so thought it worth mentioning. I took Entocort for 6 months with no problems.

Congratulations on your running! Your inspirational to many here.

Rest up,

Love,

Joanna

[tex]

Joanna,

You're quite correct about the quinolones/flouroquinolones having a bad reputation for causing tendon ruptures, and they're especially risky when used concurrently with corticosteroids. However, I don't believe that azithromycin is a part of that group, is it? You may be thinking about Cipro. Azithromycin is in a group of drugs called macrolide antibiotics. Both macrolides and quinolones are classified as bactericidal antibiotics, but macrolides are protein synthesis inhibitors - IOW, they prevent the propagation of bacteria by inhibiting bacterial protein biosynthesis, whereas quinolones and fluoroquinolones interfere with DNA replication.

You're right on the money, though, about the combination of corticosteroids and quinolones being really bad news for tendons and ligaments.

It's good to see a post from you again. How are things in Otter Tail County? We don't get to "see" you very often, since you've moved down to the lower 48.

Love,
Tex

[jillian357]

Morning Everyone!

Interesting info for sure.....I am glad to know that there isn't a lot of evidence that Entocort use will cause tendons to weaken.
I also am on Advair, which is an inhaled steroid......I'm wondering if the Entocort + Advair could be causing a double whammy of sorts.

The fact that I did complete a marathon just three weeks ago does throw a wrench in the steroid theories for sure.
Plus the Z-pack last week.....ugh, maybe it was just too much. The Achilles did start to act up right when I was taking the Zpack.
I may never know the true cause....it very well could be a byproduct of the race as an over-use injury.

I was supposed to run a half on Sunday, but have since decided to withdraw to avoid a full rupture of the Achilles. I have an appt. with an ART (active release technique) chiropractor next week to see if he can help.

No statins here, nor any protein supplements. My vitamins all come from my local health food store (Country life brand) so I am pretty confident there are no hidden triggers there.

Chicken is organic from a local Amish farm.....I've been eating it consistenly, so I don't think that is a problem either. Rice is the same....organic, plain, nothing exciting!

I do take a birth control pill......I didn't realize the risk there. Maybe it's time to re-think that.

Stress is my biggest foe....I tend to run at full throttle too much of the time, and when I do try to wean down the dose on the Entocort naturally I have anxiety about it, so that alone could be causing the stomach problems.

Sheesh, I feel like I am such a high maintenance girl anymore!!!!

Thanks everyone for helping me sort this out. You guys/gals are the best!!!

Love,
Jill

[tex]

Jill,

Of course, I'm not a doctor, but IMO, the fluticasone in the Advair is probably a bigger risk for tendon damage than Entocort. The combination, though, would obviously be riskier than the individual drugs.

The thing that catches my attention here, though, is the fact that the combination of fluticasone, (in the Advair), and azithromycin, (the Zithromax in the Z-pack), can be letal, due to what is classified as a moderate risk of a drug interaction that can cause a drug-induced prolongation of the Qt interval, together with potassium loss. Basically, with this issue, there is an increased risk for the development of what is known in medical circles, as torsades de pointes, which is a potentially fatal arrhythmia, that can occur when the QT interval is prolonged. There are a lot of risk factors, and you only have a few of them, but it's difficult to pin down actual risk, because this condition can be very unpredictable. Your doctor apparently missed this, when he or she prescribed the Z-pack, and while I don't offhand see how this could be the immediate cause of your tendonitis, it might have, and obviously, it could have created a much more serious problem. Prescribing Cipro would not have gotten around the problem, because both the quinolones and the macrolides are subject to this interaction risk:

http://www.drugs.com/drug-interactions/ ... 0-144.html

Here's more technical information on it, if you are interested:

http://www.uspharmacist.com/content/t/c ... r/c/10396/

Here's a listing of all drugs that can prolong the QT interval. As you can see, there are many, so it's a widespread problem. The most common reason for removing a prescription drug from the U.S. market in the past decade, has been prolongation of the QT interval, so hopefully, the worst offenders are already gone.

http://www.azcert.org/medical-pros/drug ... g-list.cfm

Be sure that you're eating bananas, or doing something to get potassium back into your body, in case the level has been depleted because of a reaction. Presumably, the risk has subsided by now, but if you should notice any evidence of an arrhythmia, please don't hesitate to call 911, or go immediately to the ER.

Thinking about this, since a drug interaction may have been involved, the fact that the tendonitis showed up when it did, certainly suggests that some sort of adverse drug interaction may have occurred, even though the mechanism for such a result is unknown.

I don't want to unnecessarily scare you, because the risk of an adverse event is almost certainly past by now, but just to be on the safe side, please don't run on Sunday - stick with your decision to take it easy for a while.

The birth control pill is definitely a suspect, IMO, (for the inability to wean off Entocort). Maybe Lyn will see this and respond. She recently went through a process of evaluating and experimenting with pills, patches, etc., and she was able to find a solution that worked for her, and eliminated the D.

If you mentioned earlier that you were taking Advair, I apologize, because I apparently forgot that you were taking it. Otherwise, we might have caught this before you used the Zithromax. Anyway, if you haven't had any arrhythmia problems, then you probably have nothing to worry about, and hopefully the risk is past. I would increase my potassium intake, though, at least for a few days or so, if I were in your shoes.

Love,
Tex

[jillian357]

Hi Tex,

WOW! That's quite an interesting scenario....to think I was worried about my Achilles, when I should be counting my lucky stars nothing worse happened.
Thanks for the education!

For future reference, considering I need the Advair for my asthma, what antibiotic should I be requesting in the event of an illness?

Lucky for me that I have been eating at least 2 bananas a day. I will continue to do so.

I promise that I will behave myself and not run on Sunday, no matter how good I am feeling. Thanks for looking out for me!

Thanks again!

Love,
Jill

[tex]

Jill,

These are the basic types of antibiotics:

* Aminoglycosides
* Cephalosporins
* Quinolones/Fluoroquinolones
* Macrolides
* Penicillins
* Tetracyclines

The quinolones, or fluoroquinolones, and macrolides impose the greatest risk of prolonging the QT interval, and they include:

#Fluoroquinolones:

* ciprofloxacin
* gatifloxacin
* gemifloxacin
* levofloxacin
* moxifloxacin
* norfloxacin
* ofloxacin
* trovafloxacin

#Macrolides:

* erythromycin
* clarithromycin
* azithromycin
* roxithromycin


The aminoglycosides, are not implicated for QT interval prolongation, and they include:

* amikacin
* gentamicin
* kanamycin
* neomycin
* streptomycin
* tobramycin

Unfortunately, they can only be given by injection, which limits their practically, in many situations.

The cephalosporins should be safe, and they include:

# First generation

* cephazolin
* cefadroxil
* cephalexin
* cephradine


# Second generation

* cefaclor
* cefuroxime
* cefprozil
* loracarbef


# Third generation

* cefotaxime
* cefixime
* cefpodoxime
* ceftazidime
* cefdinir


# Fourth generation

* cefepime
* cefpirome

The later generation versions are more effective than the earlier ones, and the cephalosporins are closely related to the penicillins,

The penicillins are also not implicated in the QT interval prolongation issue, but this group includes the antibiotics that are the most prone to cause C. diff infections, unfortunately, and the group includes:

* amoxicillin
* ampicillin
* bacampicillin
* oxacillin
* penicillin

The tetracyclines are another safe possibility, and this group includes:

* tetracycline
* doxycycline
* minocycline

The bad part is that the fluoroquinolones and the macrolides tend to be the most MC-friendly antibiotics available, but we have to do what we have to do, and clearly they would have to be used with considerable caution, as long as you are using Advair.

There is always the possibility that your doctor was aware of this risk, but didn't consider it to be significant enough to be concerned about, but IMO, anytime a doctor prescribes a drug where there is a clear interaction risk, the patient should always be well informed about the risks involved, and advised what to do in case of an adverse reaction; and, of course, offered another treatment option, if they didn't wish to assume the risk involved. As always, you're most welcome.

Love,
Tex

[jillian357]

Print Print Print!

Thanks Tex, I will add this list to my other stash of MC information.

Much obliged!!!!!

Love,
Jill

[Lucy]

Hi there,

Just wanted to say that I had a SEVERE case of tendonitis in one leg (pain to mid-calf) after a long hike through Grand Canyon. The hike that time was in September, and the tendonitis came around the first of November or last of October. I can't think of any other reason I would've had it, other than the fact that I was walking about 8 miles a day on my job or more, and playing tennis a couple of hours after work each day. Thing is, why hadn't it occurred BEFORE the hike if it was the walking?? Guess I'll always wonder whether it was just a delayed response.

Just curious,
Luce

[Jeanie]

Rosie,
Regarding your comment and quote on the Statins. I have been on various statins for many years. Some time back, a doctor put me on 80mg of Lipitor. I have had many problems with muscle aches, cramps and muscle weakness. I read enough on the Internet that bothered me to the point that I stopped taking them. My GP was upset about it. (I've read that Lipitor is the biggest money-maker for the Drug companies.) Since my cholesterol is quite high, I started taking Red Yeast Rice in place of the statins. I still have the muscle problems and now I read (again on the internet) that Red Yeast Rice also contains statins. Also, I have had Achilles Heel Tendonitis and a few years back I had rotator cup tendonitis. I've also had some bouts with Plantar Fasciitis. And yet the doctors have said that Lipitor is safe! (They also used to tell me that Premarin was safe. I took it for 25 years until I found out I had breast cancer. The Oncologist immediately took me off of it.) Now I am taking Arimidex and I have my doubts about that too. I'm on way too many medications which is one reason I went to the Specialist. (I just wrote about it in another post.) He sent a message to my Chiropractor (who had referred me to him) and the message said he was amazed at how well I was doing with all the problems I have. I guess I don't feel that I'm all that well. I'm hoping I can get some answers soon!

Jean

[Bifcus16]

With my old Massage Therapist hat on, it is hard to blame tendonitis on much other than poor biomechanics. Some meds and inflammation might increase your risk, but they won't cause it.

Few of us move our bodies exactly the way they were made to move. Most of us lean to one side, twist, hunch, sag, wear heels etc. All those tiny little bad habits add up, and you end up with a body that is just waiting for that one last movement that goes too far - the classic bending over to tie your shoes. It doesn't have to be backs that go, though. Achilles are vulnerable in many people because we wear heels (especially women) and end up with shortened Achilles tendons.

Three weeks after a marathon reflects that your body hasn't finished healing, and you have probably changed your training and stretching patterns. No surprises there.

A marathon is long enough for biomechanical problems to show up that you can normally get away with. Depending on your therapists skill, they might be able to give you a full body assessment and look for other parts of the problem. For example, it is common for hips to be rotated slightly, causing people to put too much weight on one foot, with a resulting subtle change of gait that eventually shows up as stress on one leg (and often a sore opposite shoulder/neck).

Other than a trained person finding your biomechnical weaknesses, the at home technique is careful all round stretching. Back, chest, legs, arms etc. Whatever stretch you find hardest to do and avoid, is almost certainly the one that is most needed - but you may have to find a modified safe version to do initially.

That said, I do find the automimmune response I get from gluten includes flare ups of my plantar fasciitis. It feels like the inflmmation response is causing tightening of lots of muscles and the good old calf muscles are especially vulnerable.

As to the pill and MC - I never had serious problems till after I stopped it. When I then tried HRT, I found that either the pills or the patches caused D. Totally clearcut enough for the GI to agree. So it makes sense that the pill might be a problem for other people. Stopping it, however, is a big ask and may not be as easy to try as it sounds to an outsider. You'll have to follow your own path on that one.

Lyn

[JLH]

Lipitor IS dangerous but not as dangerous as Crestor, IMHO. YMMV.

http://www.spacedoc.net/lipitor_thief_of_memory.html

[JLH]

https://www.statineffects.com/info/adverse_effects.htm