British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease

Smith, David; Du Rand, Ingrid; Addy, Charlotte Louise; Collyns, Timothy; Hart, Simon Paul; Mitchelmore, Philip J; Rahman, Najib M; Saggu, Ravijyot

Abstract

Summary of recommendations and good practice points
Asthma
Recommendations
Oral macrolide therapy could be considered to reduce exacerbation frequency in adults (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. This recommendation reflects the population within the AMAZES RCT which represents the highest quality evidence of macrolide therapy leading to a significant reduction in exacerbations. (Conditional)

Treatment with azithromycin should be considered for a minimum of 6–12 months to assess evidence of efficacy in reducing exacerbations. (Conditional)

Oral macrolide therapy should not be offered as a way to reduce oral steroid dose; in some individuals, this may result as a consequence of a reduction in exacerbations or symptoms. (Strong)

Good practice points
Optimisation of other asthma therapies including establishing good adherence to inhaled therapies should be performed before considering a trial of oral macrolide therapy.

Referral to a respiratory specialist or specialist asthma service should be considered prior to initiation of macrolide therapy aimed at reducing exacerbation frequency.

For safety purposes, an ECG should be performed prior to initiation of macrolide therapy to assess QTc interval. If QTc is >450 ms for men and >470 ms for women, this is considered a contraindication to initiating macrolide therapy. Baseline liver function tests should also be measured.

Patients should be counselled about potential adverse effects before starting therapy including gastrointestinal upset, hearing and balance disturbance, cardiac effects and microbiological resistance.

Microbiological screening of sputum before and during macrolide therapy may be clinically helpful in patients who are able to expectorate sputum. This would allow monitoring for development of resistance and detect changes in microbial growth to direct appropriate antibiotic therapy if required. However, the resource implications of this approach have not been assessed.

If oral macrolide therapy is considered, justification for ongoing treatment should be guided by …

Citation

Smith, D., Du Rand, I., Addy, C. L., Collyns, T., Hart, S. P., Mitchelmore, P. J., Rahman, N. M., & Saggu, R. (2020). British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax, 75(5), 370-404. https://doi.org/10.1136/thoraxjnl-2019-213929

• Journal Article Type: Review
• Acceptance Date: Apr 16, 2020
• Online Publication Date: Apr 17, 2020
• Publication Date: 2020-05
• Deposit Date: Jul 18, 2020
• Journal: Thorax
• Print ISSN: 0040-6376
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 75
• Issue: 5
• Pages: 370-404
• DOI: https://doi.org/10.1136/thoraxjnl-2019-213929
• Keywords: Pulmonary and Respiratory Medicine
• Public URL: https://hull-repository.worktribe.com/output/3497510
• Publisher URL: https://thorax.bmj.com/content/75/5/370
• Related Public URLs: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/long-term-macrolide-use/
• Additional Information: The British Thoracic Society website hosts copies of the Full Guideline, Summary, Appendices 1-4 and a supplementary file.