When guideline treatment of asthma fails, consider a macrolide antibiotic
This class of drugs has the potential to benefit patients with persistent, poorly controlled asthma and those with new-onset disease as an adjunct to first-line therapy.
PRACTICE RECOMMENDATIONS
› Consider a trial of azithromycin for patients who have poorly controlled persistent asthma and are not responding to guideline treatment with the combination of an inhaled corticosteroid and either a long-acting bronchodilator or long-acting muscarinic antagonist. B
› Consider a trial of azithromycin in addition to first-line guideline therapy for patients who have new-onset asthma. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Outcome. Ms. S’s symptoms resolved completely within months.
Evidence of benefit of macrolides in asthma
These 3 cases, taken from my practice (but with names changed), demonstrate the therapeutic potential of macrolide antibiotics for patients with asthma under specific clinical circumstances. The cases are referenced again in the following examination of the literature on macrolides for asthma
SIDEBAR
Macrolides for Asthma: Registry of Clinical Experience
More information is needed about the “real world” effectiveness of antibiotic treatment for severe refractory and new-onset asthma. If you are a prescribing clinician who cares for patients with asthma and you are considering prescribing antibiotics for asthma, you are invited to document your outcomes by entering prospective, de-identified patient data into a human subjects committee-approved online registry. To gain access to the registry, and for more information, contact the author at dlhahn@wisc.edu or visit https://www.fammed.wisc.edu/wren/resources/macrolides-for-asthma/ .
Meta-analysis. Reiter et al4 performed a meta-analysis of 12 randomized clinical trials of macrolides for long-term management of asthma in children and adults. Prolonged treatment was defined as > 3 weeks of continuous administration of a macrolide. The pooled effect of macrolides on forced expiratory volume in 1 second (FEV1) was not significant; however, a significant effect on peak expiratory flow, symptom scores, quality of life, and airway hyperreactivity was observed.
Comment: The study’s authors concluded: “Macrolides may therefore be beneficial as adjunct asthma therapy. Future trials, focusing on long-term safety and effectiveness, should use standardized outcomes and procedures.”
Cochrane meta-analysis. Kew et al5 performed a meta-analysis of 23 studies of macrolides for managing chronic asthma for the Cochrane Database of Systematic Reviews. In their review, they reported
- no significant effects of macrolides on asthma exacerbations, asthma control, quality of life, and rescue medication use; and
- significant effects of macrolides for asthma symptoms and FEV1.
Continue to: Two within-study subgroup...
