Chronic azithromycin to PREVENT COPD exacerbations

The theory is that this benefit is mostly due to azithromycin's anti-inflammatory and immunomodulatory effects. But the big concern is bacterial....

As a hospital pharmacist, you will see some patients taking chronic azithromycin to PREVENT recurrent COPD exacerbations. Preventing acute COPD exacerbations is a BIG deal. Each exacerbation worsens lung function and quality of life, plus the 30-day mortality rate is higher after a severe COPD exacerbation than a heart attack.

Adding azithromycin 250 mg/day to standard COPD therapy reduces the risk of acute exacerbations but may worsen hearing. There will be one less exacerbation for every 3 COPD patients on oxygen or with prior exacerbations that take azithromycin for one year, but one in 20 patients will experience slight hearing loss. The theory is that this benefit is mostly due to azithromycin's anti-inflammatory and immunomodulatory effects. But the big concern is bacterial resistance.

Patients on chronic azithromycin are less likely to be colonized with respiratory pathogens, but if they are, it's more likely to be with macrolide-resistant strains. Consider suggesting chronic azithromycin for patients with severe COPD and frequent hospitalizations for acute exacerbations. If patients on chronic azithromycin need antibiotics for an exacerbation, suggest avoiding macrolides. Instead, suggest amoxicillin/clavulanate (Augmentin) or a quinolone. Get our note, "Antibiotic prescribing for COPD acute exacerbation" for more information.

References

Taylor SP, Sellers E, Taylor BT. Azithromycin for the Prevention of COPD Exacerbations: The Good, Bad, and Ugly. Am J Med. 2015 Dec;128(12):1362.e1-6.
Seemungal TA, Wilkinson TM, Hurst JR, Perera WR, Sapsford RJ, Wedzicha JA. Long-term erythromycin therapy is associated with decreased chronic obstructive pulmonary disease exacerbations. Am J Respir Crit Care Med. 2008 Dec 1;178(11):1139-47.
Parameswaran GI, Sethi S. Long-term macrolide therapy in chronic obstructive pulmonary disease. CMAJ. 2014 Oct 21;186(15):1148-52.
Martinez FJ, Curtis JL, Albert R. Role of macrolide therapy in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2008;3(3):331-50.