I hate to jinx myself by writing this post, but I haven’t had an exacerbation severe enough to warrant a hospital stay, dare I say since the beginning of this year? Been roughly 4 months and counting since the last big one. May not sound like a long time, but between late 2015 and late 2017, I was in the hospital every 7 to 8 weeks on average. So to what do I owe this most welcome reprieve? Could it have something to do with the Azithromycin I started on last year?
As with most slow acting asthma controller medications, its hard to tell. It’s been my observation in living with this disease for so long, that chronic asthma symptoms in general tend to wax and wane, both in intensity and duration. You’ll experience strings of bad breathing days followed by strings of relatively good or better breathing days, regardless of any medications you might be taking. This makes it difficult to attribute the “good” periods solely to a particular drug, unless the change is verifiable with spirometry and has a prolonged effect over an extended period of time. It becomes even more difficult to ferret out what’s working and what’s not when you’re taking multiple medications. For the past 3 months however, the only em>newdrug Ive added to my maintenance regimen is Azithromycin, so Im inclined to think that this antibiotic might be at least partially responsible for this huge turn around Ive experienced so far. Of course Ive gotten my hopes before only to have them shattered. But hey, we gotta keep trying till we find what works, right?
The idea of using using Macrolides to treat persistent severe asthma and COPD has actually been around for well over a decade, but most of the studies back then were small and the trials were short, so it didn’t garner much attention from asthma specialists. More recently, a much larger and more thorough study called the AMAZES trial was conducted and the findings are pretty impressive.Those in this double blind study who received the actual drug, experienced fewer severe exacerbations after 48 weeks. 1 exacerbation compared to 1.8 exacerbations for those on placebo. That’s a reduction of 40+ percent. Even more important, is that quality of life scores also improved. It’s worth noting, that it’s still unknown exactly how macrolides work on asthma, but it is well known that antibiotics exhibit anti inflammatory effects on the body.
As mentioned in a previous post, Ive now been on Azithromycin for 6 months, and while my dyspnea level (ie, shortness of breath) hasn’t improved (as of this writing, my baseline FEV1 is 25% and my FVC 40%), my asthma in general have been much more stable with fewer swings in my peak flow. My airways still clamp up from time to time, especially with exertion or other triggers, but I haven’t experienced a snowballing of symptoms which usually leads to a ramp up on my prednisone dose, a trip to the Emergency room or even a date with a ventilator. It’s still too early to tell if this decrease in flare ups is due solely to the Azithromycin, but I am now very curious and even cautiously optimistic that that might indeed be the case.
Having said that, if indeed the the Macrolide therapy is helping, there’s no such thing as a free ride. Just like most other asthma medications, there are lots of side effects from long term antibiotic use, and one of the most common is already effecting me pretty significantly. Namely, GI upset, painful abdominal cramps and diarrhea. Fortunately, I only take the drug 3 days a week, but on those days, or least on those morning, Im pretty much confined to the house. There are other more serious side effects as well. Though rare, hearing loss, ECG changes(prolongation of the QT seg) and of course antibiotic resistance can occur. Long term studies haven’t been done yet to establish overall safety, but given my age and the severity of my lung disease, if I could somehow manage the GI problems, the trade off might be worth it.
It’s important to note, that just like biologics, antibiotic therapy would be used as an add-on maintenance therapy. One still has to take their standard asthma medications to manage daily symptoms.
If you’re dealing with severe persistent asthma and one of the newer biologics is not an option for you, you might want to research Macrolide therapy further. Here’s a family physician’s take on the results of the AMAZES trial and the role of macrolides in treating asthma. I think you’ll find it an interesting and well written article.