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
Antibiotic resistance. Exposure of populations to macrolides can increase the percentage of macrolide-resistant bacterial respiratory pathogens33; policies aimed at decreasing inappropriate macrolide prescribing can significantly lower that percentage.34 There is no evidence, however, of any detrimental effects of macrolide resistance in individual patients receiving azithromycin.33
In trials of azithromycin for the treatment of trachoma in Africa, significantly fewer deaths occurred in villages where subjects were treated with azithromycin than in villages where azithromycin therapy was not provided.35 In the United States, weekly azithromycin treatment for 3 to 12 months in adults with heart disease resulted in fewer cases of acute bronchitis and pneumonia, compared with the placebo-treated groups31,32; similar benefit for azithromycin was seen in children who had recurrent lung infection.8,36
Nevertheless, concern over the spread of macrolide-resistant bacteria to the surrounding community is a concern and a possibility—and should be the subject of future research.
Sudden cardiac death. In a Medicaid population, the risk of sudden cardiac death from taking a macrolide among patients at high risk of cardiovascular disease was 1 in every 4000 administrations.27 Compare that level of risk with the 1 in 167 risk of an acute cardiovascular event in patients with COPD who start taking a LABA.37 There is no detectable increase in the risk of sudden cardiac death when taking azithromycin in the general (ie, average cardiovascular risk) population38,39 or when azithromycin is coadministered with a LABA.3
Hearing loss. An excess of 18 (< 1%) patients affected by hearing loss, 7 of whom sought medical attention, was reported among 2004 patients who had stable coronary artery disease and had been treated once weekly with azithromycin for 12 months (P = .02, compared with placebo).32 In another study, hearing test changes leading to discontinuation of azithromycin were detected in an excess of 32
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