Azithromycin
Classification: AATC code: J01FA10
Summary
Azithromycin is associated with QT-prolongation on ECG and thus a risk of potentially fatal arrhythmias of the type Torsade de pointes ventricular tachycardia. No difference in risk between men and women has been shown for azithromycin but a known risk factor for Torsade de pointes is female sex. Caution is recommended when prescribing azithromycin to patients with ongoing proarrhythmic conditions, especially women and the elderly.
In our opinion, the described differences do not motivate differentiated dosing or treatment in men and women.
Additional information
Pharmacokinetics and dosing
No studies with a clinically relevant sex analysis regarding the pharmacokinetics or dosing of azithromycin have been found.
Effects
A meta-analysis has estimated the efficacy of a 1 g single-dose of azithromycin for treatment of genital Mycoplasma genitaliuminfection (820 men, 244 women, 426 unknown sex). The efficacy, measure as pooled microbial cure, was 78.9% for men and 86.8% for women, but the difference was not statistically significant. The overall efficacy in this study was lower than in previous ones [1].
The efficacy of azithromycin in adolescents with Chlamydia trachomatis infection has been evaluated in a prospective study (99 males, 29 females; 15-19 years old). Patients received a single-dose of 1 g oral azithromycin. Azithromycin efficacy was similar, 95% among male patients and 100% among female patients [2]. A meta-analysis (in total 726 men, 817 women) has shown that azithromycin and doxycycline are equally efficacious in achieving microbial cure in treatment of genital Chlamydia trachomatisinfection in both men and women [3].
Results from a multicenter trial of single-dose azithromycin vs. ceftriaxone for uncomplicated gonorrhea, showed that cure rates were similar in men and women for azithromycin [4].
In a retrospective observational cohort study, patients (44 men, 59 women) with severe asthma or bronchiectasis were treated with clarithromycin or azithromycin in addition to their standard treatment. Men with bronchiectasis were more likely to respond (symptom score) to treatment with macrolides than women, 53% vs. 27% [5].
Daily use of 250 mg azithromycin in patients with chronic obstructive pulmonary disease has been shown to decrease acute exacerbations to same extent in men and women [6].
A study has evaluated addition of azithromycin to high-risk patients operated for chronic rhinosinusitis failing standard management (34 men, 23 women). Patients received 250 mg three times a week. All four patients who did not respond to azithromycin treatment were women. The authors speculate that there may be a sex bias to the response to azithromycin addition [7].
Adverse effects
Azithromycin use is associated with an increased risk of death from cardiovascular causes, and the risk is similar in men and women (p=0.73) [8].
Azithromycin has been associated with prolonged QT-interval and a risk of Torsades de pointes ventricular tachycardia [8]. I the Swedish PDR, it is recommended to be careful when prescribing azithromycin to patients with ongoing proarrhythmic conditions, especially women and the elderly [9]. Among the known risk factors of drug-induced ventricular arrhythmias are female sex, hypokalemia, bradycardia, base line QT-prolongation and use of other QT-prolonging drugs [10].
Reproductive health issues
Regarding teratogenic aspects, please consult the Drugs and Birth Defects Database (in Swedish, Janusmed fosterpåverkan).
Updated: 2019-02-26
Date of litterature search: 2015-12-14
References
- Lau A, Bradshaw CS, Lewis D, Fairley CK, Chen MY, Kong FY et al. The Efficacy of Azithromycin for the Treatment of Genital Mycoplasma genitalium: A Systematic Review and Meta-analysis. Clin Infect Dis. 2015;61:1389-99. PubMed
- Beyda RM, Benjamins LJ, Symanski E, Swartz M, Risser WL, Eissa M. Azithromycin efficacy in the treatment of Chlamydia trachomatis among detained youth. Sex Transm Dis. 2014;41:592-4. PubMed
- Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transm Dis. 2002;29:497-502. PubMed
- Handsfield HH, Dalu ZA, Martin DH, Douglas JM, McCarty JM, Schlossberg D. Multicenter trial of single-dose azithromycin vs ceftriaxone in the treatment of uncomplicated gonorrhea Azithromycin Gonorrhea Study Group. Sex Transm Dis. 1994;21:107-11. PubMed
- Coeman M, van Durme Y, Bauters F, Deschepper E, Demedts I, Smeets P et al. Neomacrolides in the treatment of patients with severe asthma and/or bronchiectasis: a retrospective observational study. Ther Adv Respir Dis. 2011;5:377-86. PubMed
- Han MK, Tayob N, Murray S, Dransfield MT, Washko G, Scanlon PD et al. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med. 2014;189:1503-8. PubMed
- Maniakas A, Desrosiers M. Azithromycin add-on therapy in high-risk postendoscopic sinus surgery patients failing corticosteroid irrigations: A clinical practice audit. Am J Rhinol Allergy. 2014;28:151-5. PubMed
- Svanström H, Pasternak B, Hviid A. Use of azithromycin and death from cardiovascular causes. N Engl J Med. 2013;368:1704-12. PubMed
- AZITROMAX (azithromycin). Summary of Product Characteristics. Swedish Medical Products Agency; 2015.
- Roden DM. Drug-induced prolongation of the QT interval. N Engl J Med. 2004;350:1013-22. PubMed
- Läkemedelsstatistik. Stockholm: Socialstyrelsen. 2015 [cited 2016-04-05.] länk
Reviewed by: Mia von Euler
Approved by: Karin Schenck-Gustafsson