Budesonide × Ciprofloxacin

Fluoroquinolones, including ciprofloxacin, can cause tendinitis and tendon rupture, most often of the Achilles tendon. The risk is higher in older patients, in renal impairment, after solid organ transplantation and in patients who take corticosteroids at the same time (ciprofloxacin SmPC). The US Food and Drug Administration (FDA) label specifies age over 60 and adds strenuous physical activity and previous tendon disorders as risk factors (ciprofloxacin FDA label).

Pain, swelling and inflammation of the Achilles or other tendons, sometimes on both sides, up to tendon rupture. Symptoms can start within 48 hours of starting ciprofloxacin and as late as several months after the course ends (ciprofloxacin SmPC).

The ciprofloxacin SmPC says concomitant use of corticosteroids should be avoided because of the risk of tendinitis and tendon rupture (ciprofloxacin SmPC). It does not specify the route; inhaled budesonide can also have systemic effects, especially at high doses and in long-term use (inhaled budesonide SmPC). Ciprofloxacin is generally not given to patients who have had tendon disorders with a quinolone before (ciprofloxacin SmPC). Warn the patient about the symptoms: at the first sign of tendinitis, such as painful swelling or inflammation, stop ciprofloxacin at once and immobilise the affected limb, and do not use corticosteroids if there are signs of tendinopathy (ciprofloxacin SmPC).