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Fluoroquinolone use associated with increased risk for carpal tunnel syndrome
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Fluoroquinolone use was linked with an increased risk for carpal tunnel syndrome, according to researchers in Canada.
“In 2013, the FDA issued a label requirement of association between use of fluoroquinolones and neurologic conditions such as peripheral neuropathy, and musculoskeletal conditions such as tendinopathies,” Jasmine Z. Cheng, MD, of the faculty of medicine at the University of British Columbia, Vancouver, and colleagues wrote. “Given that [fluoroquinolones] are widely prescribed in North America, a potential risk of these drugs inducing carpal tunnel syndrome (CTS) should be examined in a large epidemiologic study.”
Cheng and colleagues performed a case-control study using the LifeLink health care claims database, reviewing information from about 6 million patients living in the United States. All patients were aged 15 to 60 years, and were documented in the LifeLInk database between 2006 and 2014.
For their primary analysis, the researchers identified 75,895 cases — defined as individuals with newly diagnosed idiopathic CTS — and 758,950 controls without CTS. They also included 48,533 cases with an additional nerve conduction procedure and 485,330 controls in a sensitivity analysis. Cases showed slightly higher incidences of comorbidities, including diabetes, obesity, hypothyroidism, rheumatoid arthritis and lupus compared with controls, the researchers reported.
Any fluoroquinolone use in the previous year was associated with a 34% increased risk for CTS (RR = 1.34; 95% CI, 1.31-1.37), an association that increased slightly to 36% in the sensitivity analysis (RR = 1.36; 95% CI, 1.32-1.4), according to Cheng and colleagues.
Both the primary and sensitivity analyses showed risk increases with current fluoroquinolone use (RR = 1.19; 95% CI, 1.12-1.26 for primary; RR = 1.2; 95% CI, 1.12-1.29 for sensitivity), recent use (RR = 1.32; 95% CI, 1.27-1.38 for primary; RR = 1.32; 95% CI, 1.25-1.39 for sensitivity) and past use (RR = 1.37; 95% CI, 1.34-1.41 for primary; RR = 1.41; 95% CI, 1.36-1.45 for sensitivity), the researchers wrote. Cheng and colleagues attributed this to a possible delayed response with fluoroquinolone use.
“Our study results demonstrate an increase in the risk for CTS with fluoroquinolone use,” the researchers wrote. “Patients taking these drugs should be aware of the warning of adverse side effects. Those who experienced pain, numbness, tingling and burning along median and ulnar digits may be at risk of developing CTS and should discuss their symptoms with their primary care physician.” – by Andy Polhamus
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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This database study examined patients exposed to fluoroquinolone antibiotics compared with patients without exposure. Patients were followed from 2006 to 2014, and prescriptions, physician visits, diagnoses and procedures documented in the database were examined.
The authors identified an increase in diagnoses of CTS in patients who had fluoroquinolone use within the past year, with an RR of 1.34. The authors suggest that this indicates that use of fluoroquinolone antibiotics confers an increased risk for developing CTS, particularly in a delayed onset fashion.
Problems with this study are an increased incidence of factors known to increase the risk for CTS in the “case” group compared with the control group, including obesity, diabetes, hypothyroidism, rheumatoid arthritis and lupus. Moreover, patients who have used fluoroquinolone antibiotics may be intrinsically different than patients who do not, by virtue of having different medical conditions that may make them more prone to require antibiotics and also may confer a higher risk for CTS. Alternatively, patients who receive antibiotics may do so because they present more often and have a better opportunity to interact with the health care system than those who do not. Likewise, patients who have better access to medical care may receive additional diagnoses of CTS, whereas patients who do not have such good access may go undiagnosed.
The study also fails to document the results of the electrodiagnostic testing used for identification of some cases. As a hand surgeon, I often see patients referred with a “diagnosis” of CTS on the electronic medical record as a reason for consultation or electrodiagnostic testing, but my clinical examination or electrodiagnostic testing may identify an alternative cause of symptoms, such as peripheral neuropathy, cervical radiculopathy, other peripheral compressive neuropathy, or generalized hand pain without any nerve symptoms at all.
In summary, this study provides a gentle reminder that use of antibiotics (as well as other medications) may not be without potential complication. However, although the results suggest a correlation, there are a number of factors in this study that require additional clarification. In addition, correlation does not equate causation, and further study is indicated to determine what, if any, role use of fluoroquinolone antibiotics may have in causation of CTS.
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