[CIS PIDD] [cis-pidd] Long term Azithromycin for IgA deficiency & recurrent bronchitis

Tue Aug 29 17:40:46 EDT 2017

What is the prophylactic regimen? I have seen 5mg/kg/d, 5 or 10mg/kg M-W-F
and 20mg/kg once a week. I suspect that both dose and frequency play a role
in the potential for toxicity. There is little or no data on either safety
or efficacy. It is too bad that there is not enough money in antibiotic
prophylaxis for a drug company to take on a study.
Richard Wasserman
Dallas

On Tue, Aug 29, 2017 at 5:34 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
wrote:

>
>
> Dr. Ress:
>
>
>
> I have yet to see any formal protocols or guidance for monitoring for
> long-term azithromycin.  The ATS/IDSA guidelines on nontuberculous
> mycobacteria do mention monitoring for toxicity, but they’re not really
> specific on the details.
>
>
>
> That said, in my (relatively short) career, I’ve had one kid get tinnitus
> on treatment-dosed azithromycin (he was on the drug for 2 - 3 months, for
> what it’s worth), where we did find out that he was indeed
> supratherapeutic.  I also had one previously healthy kid get in Torsades
> after a single dose of ondansetron.  While it’s not my usual practice to
> ask for an EKG before prescribing short-term azithromycin or ondansetron to
> healthy kids, I’ve ended up glancing at the cardiopulmonary monitor to just
> make sure the QT looks normal.
>
>
>
> A professor of mine went by the adage, “the punishment should fit the
> crime.”  My 2 cents – the longer or higher the dosing, or if the patient is
> on other QTc-prolonging agents , the more monitoring they’ll  get.  EKG,
> LFTs, hearing, drug levels – probably in that order of priority.  I concede
> this is probably a high number-needed-to-treat scenario.
>
>
>
>        - Karl
>
>
>
> Karl O. A. Yu, M.D., Ph.D., F.A.A.P.
>
> Scientist II and Assistant Director, Center for Infectious Diseases and
> Immunology
>
> RGH Research Institute | Rochester General Hospital | Rochester Regional
> Health
>
> 1425 Portland Ave., Room R-403, Rochester, NY   14621
>
> Tel  585-922-3709 <(585)%20922-3709>  |  Fax  585-922-2415
> <(585)%20922-2415>
>
>
>
>
>
>
>
> *From:* cis-pidd at lyris.dundee.net [mailto:cis-pidd at lyris.dundee.net] *On
> Behalf Of *CIS-PIDD
> *Sent:* Tuesday, August 29, 2017 4:45 PM
> *To:* CIS-PIDD
> *Subject:* Re: [cis-pidd] Long term Azithromycin for IgA deficiency &
> recurrent bronchitis
>
>
>
> Hi Stan,
>
>
>
> Admittedly I am a 'low-but-not-undetectable-IgA-deficiency' skeptic.  In
> other words, in these situations I believe there are other factors
> contributing as much or moreso than the IgA.  Truth be told, even with
> undetectable serum IgA, I am always searching for additional contributing
> factors rather than looking to antibiotics to solve all.
>
>
>
> My approach to these patients is to thoroughly re-evaluate things from an
> allergic rhintis, chronic rhinosinusitis and asthma standpoint and maximize
> therapy based on history, exam and diagnostics (PFTs, , allergy testing,
> sinus CT if applicable).  Once this has been re-visited and a consistent
> management plan (e.g. nasal saline irrigation, intranasal steroids, ICS,
> AIT, etc.) is in place I will work to discontinue the azithromycin or other
> prophylactic antibiotics.
>
>
>
> I am not sure if anyone has determined a finite length of azithromycin
> prophylaxis at which adverse events start to occur.   I have seen children
> and adults on azithromycin fpr years.  Admittedly I do not routinely do
> hearing tests or ECGs.  Perhaps I should?  I alos would like to hear
> others' approaches.
>
>
>
> -j
>
>
>
> jason raasch, md
>
>
>
> Midwest Immunology Clinic
>
> Minnesota
> ------------------------------
>
> *From:* cis-pidd at lyris.dundee.net <cis-pidd at lyris.dundee.net> on behalf
> of CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
> *Sent:* Tuesday, August 29, 2017 2:14:48 PM
> *To:* CIS-PIDD
> *Subject:* [cis-pidd] Long term Azithromycin for IgA deficiency &
> recurrent bronchitis
>
>
>
> Dear Colleagues,
>
>
>
> I've followed a 16 year-old adolescent since 2014 with mild IgA deficiency
> 0.36 (0.6-3.0) & low IgG4 (0.01). She had severe bronchitis aged 9 years
> and thereafter she has had recurrent annual viral infections with
> bronchitis. She has allergic rhinitis treated with nasal steroids and
> recently has been on a steroid MDI for asthma under the care of a
> pulmonologist. Prior to steroid therapy for the asthma she was on
> prophylactic Azithromycin from January to November 2015. In February 2016
> she developed bronchitis requiring 2 antibiotic courses,  and went back on
> Azithromycin 3 times a week thereafter. In May 2016 she had normal
> lymphocyte subsets and total memory B-cells, but class-switched B-cells
> were low at 6.4%. Serum MBL, classical & alternate complement pathways, and
> lymphocyte proliferation were all normal, and there was a strong response
> to vaccination with tetanus & pneumovax 23 with protective specific IgG
> levels. I have not seen her since May 2016 but I understand she has now
> been diagnosed clinically with bacterial tonsillitis by her family
> physician (but no lab evidence), and is still on Azithromycin AB 3 times a
> week.
>
>
>
> My concern is for how long can one continue AB prophylaxis in this
> scenario? I usually prescribe it only for 6 months over winter in young
> scholars with IgA deficiency and recurrent infections, to help them cope
> with school.  Also, what sort of routine precautions are advisable (annual
> hearing tests? 6 monthly ECG for QT interval prolongation?)
>
>
>
> I’d appreciate any advice and hearing what others do & about routine
> monitoring protocols.
>
>
>
> Thanks,
>
>
>
> Stan
>
>
>
> Stanley Ress
>
> Emeritus Associate Professor of Medicine, UCT
>
> Specialist physician & Clinical Immunologist,
>
> UCT Private Academic hospital, Anzio Road, Observatory,
>
> Cape Town, 7925 South Africa
>
> TEL:INTERN. + 2721-4421966 <+27%2021%20442%201966> or 4421816 FAX:
> "    + 2721-(0)865173095
>
> Cell: 0833115482
>
> email: stan.ress at uct.ac.za
>
>
>
>
>
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-- 
Richard L. Wasserman, MD, PhD
Allergy Partners of North Texas
7777 Forest Lane, Suite B-332
Dallas, Texas 75230
Office (972) 566-7788
Fax (972) 566-8837
Cell (214) 697-7211

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