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

Wed Aug 30 16:15:03 EDT 2017

For children I use 10mg/kg twice a day one day a week. I have found that
20mg/kg as a single dose frequently causes GI upset.
Richard Wasserman
Dallas

On Wed, Aug 30, 2017 at 4:03 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
wrote:

> Thanks to Jason & Karl for your very helpful suggestions on management and
> monitoring. Richard raises a highly pertinent question on Azithromycin dose
> and frequency. Based on the pharmacokinetics of the drug with activity
> lasting  7-10 days, over the past 5 years pulmonologists here have
> successfully treated cystic fibrosis patients and selected cases of
> bronchiectasis with 1 gram weekly (for adult > 50 kg body weight). I am
> told that some CF centres in Australia have adopted the same regimen.
>
>
>
> Stan
>
>
>
> *From:* cis-pidd at lyris.dundee.net [mailto:cis-pidd at lyris.dundee.net] *On
> Behalf Of *CIS-PIDD
> *Sent:* 29 August 2017 11:41 PM
> *To:* CIS-PIDD
> *Subject:* Re: [cis-pidd] Long term Azithromycin for IgA deficiency &
> recurrent bronchitis
>
>
>
> 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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-- 
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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