Prophylactic azithromycin for COPD

18 Nov

Albert, Richard K, John Connett, William C Bailey, Richard Casaburi, J Allen D Cooper, Gerard J Criner, Jeffrey L Curtis, et al “Azithromycin for prevention of exacerbations of COPD..” The New England journal of medicine 365, no. 8 (August 25, 2011): 689–698. PMID 21864166

Everyone is probably aware by now of the “immunomodulatory” effects of macrolides. I don’t really know what that means but I would like to know if it matters. This trial goes some way to help answer the question.

Methods

  • publicly sponsored
  • authors all conflicted of course
  • RCT placebo of COPD patients to take daily 250 azithromycin or placebo
  • you didn’t have to be that sick to get into the trial (ie one dose of steroids in the past year would do fine)
  • they excluded long QTs and those on drugs that might prolong QT (they don’t mention statins specifically here; macrolides and statins are thought to be problematic)
  • outcome was time to first exacerbation
  • they also measured for resistance to certain bugs but they make no mention of candida or diarrhoea

Results

  • n = 1100
  • time to first COPD exacerbation was 266 days vs 174 days favouring azithromycin
  • no change in death or cardiac death or resistance patterns

The big problem here is that people will have to take this drug for the rest of their lives presumably, and with only 12 months follow up we don’t know if the benefit tails off never mind the side effects going up. There are so many drugs that prolong the QT and patients with COPD will be on a lot of them so it’s difficult to know if this is something we can do in real life.

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