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When considering management of airways disease, there are two main aims of therapy: to reduce symptoms, most commonly breathlessness and cough, and to reduce exacerbations. There has been interest in a potential role for macrolide antibiotics in reducing exacerbations for some years. Macrolides are compounds with a macrocyclic lactone ring of 12 or more elements and commonly used examples are erythromycin, clarithromycin and azithromycin. There has been interest in a non-antimicrobial action of these drugs, a so-called ‘immunomodulatory effect’, following observations of a possible steroid-sparing effect when used long term in asthma. The mechanism for a non-antimicrobial effect is unknown at present and no macrolide antibiotic is currently licensed in the UK for long-term low-dose use as an immunomodulatory agent.1
The British Thoracic Society (BTS) published a guideline on long-term macrolide use for adults (aged >16 years) with respiratory disease in 2020.1 Unlike other publications, which limit their remit to macrolides in specific disease entities, the BTS guideline covers asthma, bronchiectasis and chronic obstructive pulmonary disease (COPD). This is to be welcomed as there is often clinical overlap of the three conditions; it is not uncommon for more than one of these conditions to occur in a particular patient. There is brief mention of use in bronchiolitis obliterans, chronic cough, organising pneumonia and diffuse panbronchiolitis. Use in cystic fibrosis (CF) is specifically excluded (there is a National Institute for Health and Care Excellence evidence summary which covers the use of azithromycin in CF2) as is use in chronic rhinosinusitis.
This is the first BTS guideline to use the grading of recommendations, assessment, development …
Competing interests None declared. Refer to the online supplementary files to view the ICMJE form(s).
Provenance and peer review Commissioned; externally peer reviewed.
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