Back on azithromycin

My little boy has been gradually reducing his meds to see if he could hold on lower doses....but now flixotide has been put back up and it looks as if he'll be back azithromycin. He first went on azithromycin when he was 2 and has only been off it for about 4 months and we're seeing his asthma control slip badly. Tomorrow we have an urgent review with his consultant who was not very happy about his low peak flows when he was 'well' and is very unhappy about the big slip over the last month. He says that he'll prob re introduce the antibiotic because that improved him so dramatically then in Jan we'll need to start reinvestigating why it helps so much. He's on such high doses of everything we were so happy to start withdrawing and it feels so sad to be putting everything back again but he was so poorly and to see that slip start happening is just awful. Finished h is week course of pred with still a very low pf good job he's being seen tomorrow. I was so impressed that when I spoke to asthma nurse she arranged for this urgent appointment.

I feel so blur about this all because I was so excited that he was slowly withdrawing all his high dose support. Sorry about the waffle.

Margot x.

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Azithromycin use in Asthma

Hey Margot,

I'm sorry to hear that you son is suffering with his asthma so much. It can be so frustrating for all involved when withdrawl of medication leads to a deterioration in control. However, please take comfort in the fact that given that the azithromycin was so successful in the past, hopefully it should be again!

I'm glad you've been able to get your son seen by the consultant. How did the appointment go? Is your son any better?

I wasn't sure from your post if you understood the mechanism of action of this type of medicine (an antibiotic of the group known as macrolides)- ie how they work. Please feel free to ignore all of the following if you have already been told in clinic! The mechanism of action is not fully understood, but there are many proposed ways it is thought to act in asthma to improve control and decrease the doses of steroids required. I'll try to explain in this post.

Obviously - when the term 'antibiotic' is used most people think of the treatment of infection, which is the usual purpose of the type of drug... and indeed, in some cases- people with asthma may have chronic undetected infection which essentially cause no or little symptoms or signs except a deterioration in asthma control. They don't necessarily have to be coughing up unpleasant sputum(and at your sons age -most children swallow it rather than it being expelled anyway, so you may not know about it even if he did have green purulent sputum), and don't need to have a temperature or any other classic signs of infection.

Depending on what dose is prescribed-however, when azithromycin is used long term in asthma -it can actually be at a level that is too low to have actual antibiotic activity against infection.

Of course - this then raises the question of why the drug is prescribed in asthma, and how it works!

To understand this, I think the best thing is to think about what happens in asthma. Asthma is a chronic inflammatory disease characterized by reversible airway narrowing and bronchial hyperresponsiveness (BHR). BHR is an abnormal, exaggerated response to a trigger. This means that in a patient with asthma, the airways narrow in response to a trigger that wouldn't normally elicit a response in a healthy lungs. This narrowing is thought to occur by a number of mechanisms...increased secretions, smooth muscle contraction (bronchoconstriction) and airway wall thickening. The processes behind these events are rather complicated, but include the involvement of inflammatory cells such as eosinophils and neutrophils (types of white blood cell) and a huge variety of chemicals that occur in the body including histamine.

This macrolides (which include azithromycin, erythromycin, clarithromycin) are thought to have an anti-inflammatory and immunomodulatory (affecting the immune response) effect in the lung. They are also used in other chronic lung diseases such as cystic fibrosis and bronchiectasis for these properties. Most commonly, in asthma- azithromycin is used.

It is thought to reduce bronchial hyperresponsiveness. Therefore, when BHR is reduced... the lungs are less 'twitchy' and less likely to constrict to any particular trigger-so for example, if exercise is one of your son's triggers- with decreased BHR he would be able to run around further and play harder before his asthma would play up). The medicine is thought to decrease the action of certain types of inflammatory cells within the lung tissue, decrease inflammatory chemicals release into the lung, reduce inflammation, control mucus hyperproduction and improve the lung's ability to defend itself against infection. All these events leads to better asthma control.

I've been on constant azithromycin for a couple of years now, and whilst I wouldnt say it was a wonder drug for me - I do think it does help to an extent, and I havent noticed any problems with it.

Please let me know how your son is getting on, and don't hesitate to PM me if you have any questions.

Best wishes,

KSD

{post edited for spelling}

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Thank you

for your reply. No I didn't really understand the action of the azithromycin. The consultant was lovely. He always is and saw us at such short notice because Alfie's asthma is so volatile. Anyway the verdict is he wants to do a special ct scan of his lungs 'narrow cut' I think he called it so he can see if there's any lung damage (he thinks there is). Apparently lung damage would explain why Alfie doesn't respond typically to normal asthma medication. So he's back on the azithro, back to his super high steroid dose and still barely keeping a peak flow of 150. We're visiting relatives in New Zealand and have a letter from his consultant to give any Dr we need to see while we're out here, I was hoping that the warmer drier weather would help 'pull him up by his bootstraps' but no such luck yet.

I feel a little shell shocked as I had hoped that his really scary days were past us and they don't seem to be and his consultant said that he thinks the key is preventing any further damage to his lungs and then treating the ongoing asthma but more damage would make things harder to treat.

Thank you again,

Margot x.