LT macrolide use

Question 1

Condition for starting macrolides in asthma?

Answer 1

50–70 years with ongoing symptoms despite
>80% adherence to high-dose inhaled steroids
(>800 µg/day) and at least ONE exacerbation
requiring oral steroids in the past year
BONUS: AMAZES RCT for evidence- statistically significant but not the case for the other large trial AZISTAT

Question 2

What is the QTc threshold for withholding macrolides?

Answer 2

QTc is >450
ms for men and >470 ms for women

Question 3

What tests need to be done prior to starting LT macrolide therapy?

Answer 3

1. ECG- QTc interval- checked at baseline and 1 month
2. Liver function tests- need monitoring at baseline, 1 month and every 6 months
3. AAFB culture to look for NTM

Question 4

Condition for starting macrolides in bronchiectasis?

Studies?

Answer 4

3 or more exacs/yr despite:
- optimised airway clearance
- attendance at PR

Bonus: main body of evidence are from:
BAT: azithro 250/placebo 1 yr
EMBRACE: azithro 500/placebo 6 months
BLESS: erythro/placebo 48 weeks

Question 5

what is the optimal dosing in bronchiectasis of azithromycin?

Answer 5

500mg x3/week, but can start at 250mg and titrate up

Question 6

Condition for starting macrolides in COPD?

Trials?

Answer 6

3 acute exacerbations requiring steroid therapy and at least 1 exacerbation requiring hospital admission /year (BTS)
‘freq’ exacs (4 or more) with daily sputum prod (NICE)

CT to look for bronchiectasis- and subsequent optimisation

optimised:
smoking cessation
inhaler
technique
self-management care plan
airway clearnance
PR

BONUS
- Albert et al Azithro 250 daily 1yr
- He et al erythro 150 TDS 6 months
- Seemungal et al erythro 250 BD 1yr
- Suzuki et al erythro OD 1yr
- Uzun et al azithro 500 1yr

Question 7

what do you need to know about a patients cardiovascular risk before starting macrolides?

Answer 7

• history of heart disease
• previous low serum potassium measurements
• a slow pulserate
• a family history of sudden death
• known prolonged QT interval

Question 8

what microbes are macrolides effective against?

Answer 8

many Gram positive bacteria
some Gram-negative organisms
some ‘atypical’ respiratory pathogens such as legionella and mycoplasma
some mycobacterial species

Question 9

What do other guidelines say about starting Macrolides in COPD?

Answer 9

GOLD 2019- consider in those optimised still exacerbating

NICE 2018- 4 or >/yr exacs, daily sputum production, prolonged or hospital stays

ERS/ATS - mod/severe COPD with exacs