Macrolides

Question 1

Indications for macrolide use in asthma patients

Answer 1

On optimised high dose ICS (>800mcg/day) with good adherence (>80%)
1 or more exacerbations requiring oral steroids in the past year
Aged 50-70 (as per AMAZES trial)
Treatment should be for 6-12 months

Question 2

What are the indications for macrolide therapy in COPD patients?

Answer 2

More than 3 exacerbations requiring steroids in the past 12 months, with at least 1 exacerbation requiring hospitalisation
Treatment for at least 6-12 months
Need ECG monitoring before treatment and sputum samples for NTM
Usual treatment dose 500mg 3x weekly

Question 3

What are the indications for macrolide therapy in bronchiectasis?

Answer 3

High exacerbation rates: 3 or more exacerbations per year
Start at 250mg 3x weekly and titrate upwards to 500mg
Could also consider azithromycin 250mg OD or erythromycin 400mg BD
Treat for a minimum of 6 months
Optimise airways clearance and pulmonary rehab
Should investigate for NTM prior to commencing therapy (with at least 2 weeks off antibiotics)
Consider drug holidays to reduce the chance of long-term resistance

Question 4

Azithromycin therapy after lung transplant

Answer 4

Azithromycin low dose (250mg TDS) can be used to prevent bronchiolitis obliterans (BOS) after transplant.
It may also be considered for treatment to BOS at 250mg dose on alternate days