Daily Antibiotic May Cut COPD Flare-ups

What Is the Doctor's Reaction?

Chronic obstructive pulmonary disease (COPD) includes a group of lung problems with three things in common:

• They impair the flow of air into and out of the lungs.

• Damage to the lungs and bronchial tubes is permanent.

• In general, symptoms get worse over time.

Most people with COPD have both chronic bronchitis and emphysema.

COPD is one of the leading causes of death in the United States. About 1 in 20 deaths is directly related to COPD. This does not include deaths caused by pneumonia in people who have COPD.

Smoking is the major cause of COPD. More than 80% of people with the disease are current or past smokers.

Drugs for COPD cannot slow down the eventual decline in lung function. However, they can allow people to breathe a little easier, with less coughing. Commonly used drugs for COPD help people feel better in different ways.

• Corticosteroid inhalers can reduce inflammation.

• Beta agonist inhalers can improve air flow by relaxing the airways. Some inhalers combine a long-acting beta agonist with a corticosteroid. These include Advair and Symbicort.

• Anticholinergic inhalers can improve air flow. They have a different way of relaxing bronchial tubes. One of the most popular inhaled drugs used to treat COPD is tiotropium (Spiriva).

These drugs help to decrease symptoms of COPD. They also help some people to avoid flare-ups, called COPD exacerbations. Typical symptoms of a flare-up include:

• Increased coughing

• Change in the color of coughed-up mucus

• Increased shortness of breath

• Fatigue

• Wheezing

Many COPD flare-ups start with a bacterial or viral infection in the bronchial tubes. An antibiotic is usually part of the treatment when a flare-up occurs.

Past studies have looked at whether taking a daily antibiotic could help prevent flare-ups. The results have been mixed. Until now, the benefits have not clearly outweighed the side effects.

New research suggests that daily azithromycin can help to prevent flare-ups. Azithromycin is a common antibiotic. The one-year study compared 250 milligrams of the drug per day to a placebo. The New England Journal of Medicine published the study results today.

The COPD patients who took the azithromycin went an average of 100 days longer without a flare-up than those taking the placebo. They had fewer flare-ups overall. And they reported a better quality of life. One unexpected side effect did occur. About 5% of patients who took azithromycin had mild hearing loss.

What Changes Can I Make Now?

Quit smoking. This is the only proven way to prevent ever having COPD. If you already have COPD, it is the only chance you have to prevent it from getting worse.

Where does daily azithromycin fit into the drug treatment of COPD? Currently, I would consider this for some patients with COPD. You may be a candidate for this treatment if you have had at least one severe flare-up or require home oxygen therapy.

Before starting azithromycin, you would need to have an EKG (electrocardiogram) and a hearing test. You should not take daily azithromycin if you have:

• A resting heart rate of greater than 100 beats per minute

• A specific abnormality on the EKG called a prolonged QT interval

• Impaired hearing

These "exclusions" apply to daily use. A person with any of these findings could still be considered for 5 to 7 days of this drug to treat a flare-up. Azithromycin could be prescribed if the heart rate was not very high and the QT interval was not very abnormal.

What Can I Expect Looking to the Future?

You can expect doctors to begin prescribing azithromycin for people with severe COPD. This drug has a long half-life, meaning it stays in the body for a few days after you stop taking it. Therefore, it's likely that one pill every other day (three times per week) would be as effective as a 250 milligram pill daily.