I'm anesthesiologist/pain management physician who is a regular participant in the pain medicine forum and noton this forum. I would like to get the opinion of the participants in this forum on the use of 3X/week (M,W,F) zithromycin in a dose of 250mg PO for a "hypothetical" patient late 80s, obese 40 pack-year smoker who quit 25 years ago with a diagnosis of COPD with bronchiectasis. Already on TID DuoNeb, BID Pulmicort. oxygen at 2.5l/min around the clock. One very well respected academic chief of pulmonary recommended it to "reduce the number of bronchitic episodes". The local, well trained pulmonologist has recommended against it stating that it has no utility in the "type" of bronchiectasis. The academic pulmonologist als said its use in this setting is for its "immunomodulatory effect". Any experience or thoughts regarding this??
Azithromycin - 3X/week
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Macrolide prophylaxis is somewhat controversial. It certainly has a role in both CF and non-CF related bronchiectasis. The EMBRACE trial showed that it reduces non-CF bronchiectasis exacerbations (Lancet 2012;380:660-7). Macrolide prophylaxis also has a role in preventing COPD exacerbations. Richard Albert and colleagues published a trial in 2011 showing that daily azithromycin reduced acute exacerbations of COPD (N Engl J Med 2011;365:689-98). There are certainly other articles that have addressed this issue. Herath, et al, published a clinical review in JAMA in 2014, which supported the use of azithromcyin for this purpose (JAMA. 2014;311{21}:2225-2226). There was also a recent Cochrane review that came to a similar conclusion. Anecdotally, I have a couple of severe COPD patients on the 3X/week regimen who had frequent severe exacerbations (resulting in multiple hospitalizations). Both patients seem to be tolerating azithromycin well, and it has been effective in reducing the frequency of their exacerbations over the last 12-18 months. Obviously, macrolide therapy is not without risks, especially QTc prolongation, arrhythmias, and hearing loss. You have to weigh these risks against the risk of frequent exacerbations. For this reason, I do not put all of my severe COPD or bronchiectasis patients on azithromycin prophylaxis. If the above mentioned patient has frequent acute exacerbations of COPD and/or bronchiectasis, he/she might be a candidate for prophylaxis. The idea that there is no role for this therapy in non-CF bronchiectasis and/or severe COPD is not true.
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Nash's response was excellent. What you are seeing (disagreement amongst pulmonologists) is occurring on a national level as well, well-respected pulmonologists on both sides of the issue. There's no general consensus on this issue right now.
Thank you both for your response. We face similar controversial issues in my field; the primary one currently is chronic opioid therapy.
Other than the cardiac issues and otologic issues what potential risks are there? Is there a down side to eliminating Azythromycin as a PO drug to use for outpatient management of acute exacerbations if a patient is on it chronically? The second opinion university based pulmonologist opined that the bronchiectasis was mainly on the basis of chronic aspiration. His only recommendation was not to lay flat for 2 hours after eating. That is not an issue since she sleeps in a recliner. There are definitely swallowing issues as she has had 3-4 episodes of "steak-house" syndrome where a food bolus has obstructed her esophagus. None of the episodes have required intervention. Are there other ways to manage the presumed chronic aspiration/microaspiration in theses patients?
Beyond supplemental oxygen, ipatropium bromide/albuterol, budesonide what else can you offer these individuals, other than PO steroids? She is already using an Acapella flutter valve and SmartVest albeit perhaps ineffectively given her inability to perform a huff cough. I see mention here of N-Acetylcysteine; is that a viable option?
Other than the cardiac issues and otologic issues what potential risks are there? Is there a down side to eliminating Azythromycin as a PO drug to use for outpatient management of acute exacerbations if a patient is on it chronically? The second opinion university based pulmonologist opined that the bronchiectasis was mainly on the basis of chronic aspiration. His only recommendation was not to lay flat for 2 hours after eating. That is not an issue since she sleeps in a recliner. There are definitely swallowing issues as she has had 3-4 episodes of "steak-house" syndrome where a food bolus has obstructed her esophagus. None of the episodes have required intervention. Are there other ways to manage the presumed chronic aspiration/microaspiration in theses patients?
Beyond supplemental oxygen, ipatropium bromide/albuterol, budesonide what else can you offer these individuals, other than PO steroids? She is already using an Acapella flutter valve and SmartVest albeit perhaps ineffectively given her inability to perform a huff cough. I see mention here of N-Acetylcysteine; is that a viable option?
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I've started using oral nac, and anecdotally I'm liking what I'm seeing, granted I use it more in PTs who can not get daliresp. Getting as a prescription is expensive, last of told me $400/month, so I've taken to what I think group therapy suggested several months back and getting otc tabs. Or I use it on my in-house PTs that are taking longer than I like to break the bronchospasm also with anecdotal working well., until nephro stops it thinking I'm using it for renal protection.
It's been a little since I've researched the data but I was understanding that Macrolide data was not used in conjunction with ICS/LABA treatment.
It's been a little since I've researched the data but I was understanding that Macrolide data was not used in conjunction with ICS/LABA treatment.
In Albert's study from 2011, about 20% of patients were taking an ICS/LABA and 45-50% were on ICS/LABA/LAMA therapy.
Out of curiosity, what does of oral NAC are you using?
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That's not the study I was thinking of, the series I had remembered were more erythromycin based, I just found one from 09, they don't specify LABA/LAMA rates, only ICS, which was 50%, so your data is more relevant to this topic
Most of the OTC of nac are labeled as 600mg, so I use 600mg bid as the study was set up,
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Is Roflumilast an option? I would use that first before resorting to chronic macrolide therapy if at all possible.
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Have yall made sure the pt is doing routine bronchiectasis bronchial hygiene? If they have chronic infected type, don't forget daily breathing treatments, flutter valve/chest physiotherapy and know what her colonization pattern is
Again, I'm not a pulmonologist but I see tons of medicare patients with multiple comorbidities. I see many on home supplemental oxygen and many on steroids chronically. I treat many with vertebral compression fractures. I have not seen a single patient on Roflumilast in this fairly rural community that I practice in currently. I have been practicing in this community since prior to 2011 when I believe that it became FDA approved. I wonder why I see no one on the drug. Is it the old fashioned backwoods medicine practiced in this community? Is it the cost of the drug? Is it the side effect profile? In fact, our son's nanny's father died in hospice of "end stage" COPD about a month ago. Toward the end he was admitted to the hospital at least every 4 weeks. I know for a fact that he was not on Roflumilast and was never offered the drug.
We have tried every airway clearance tool imaginable. With the lung flute she can't even manage to get the "reed" to vibrate. She is current using both the Acapella and a SmartVest. However, I cannot manage to get her to perform a "huff" cough. In the absence of that ability can these modalities be truly effective?
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They're better than nothing, if they're chronically hypercapnic, you could use a HS NPPV and have the demand set it up with a cough assist device as well.
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Interesting. I have started many patients on it and it is usually well tolerated in my experience. The most common side effects are GI related. It is an expensive drug though. Maybe that is why you don't see it much in rural communities.
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It's funny your doing this. Niewoehner didn't want to study azithromycin when the group met to decide what to study with the COPD trial - he wanted to study NAC! He's been using it ever since. Look for his own data to come out in a few years. That's if he gets around to it. Probably needs the right fellow to type it up for him. Lol.
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Cost, side-effect tolerance, and if you actually look at the multiple studies (esp the international trials), it isn't that great of a drug. Since it doesn't help with immediate symptom relief, and a lot of patients develop nasty GI side effects, a lot of my patients who start on it eventually stop it after a short period.
COPD isn't athma (a lot of PCP and sometimes pulmonologist forget this) - it's a chronic progressive disease and sometimes no matter what we do, patients progress and die from COPD. Mortality rate for COPD have not changed much in the last 10 years (if you look at death from COPD from 1999-2009)