{"id":1888,"date":"2012-05-16T17:07:37","date_gmt":"2012-05-16T21:07:37","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=1888"},"modified":"2018-04-15T07:11:01","modified_gmt":"2018-04-15T11:11:01","slug":"azithromycin-linked-to-cardiovascular-death-not-a-placebo-after-all","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/azithromycin-linked-to-cardiovascular-death-not-a-placebo-after-all\/2012\/05\/16\/","title":{"rendered":"Azithromycin Linked to Cardiovascular Death &#8212; Not A Placebo After All"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/05\/z1.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-2702\" title=\"z\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/05\/z1.png\" alt=\"\" width=\"288\" height=\"288\" \/><\/a>I&#8217;ve <a href=\"http:\/\/blogs.nejm.org\/index.php\/its-time-for-antibiotic-placebos\/2011\/08\/31\/\" target=\"_blank\" rel=\"noopener\">commented before<\/a> about azithromycin, that remarkable antibiotic that clinicians seem to prescribe for, gosh, you-name-it.<\/p>\n<p>But a paper just published in the <em><a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1003833\">New England Journal of Medicine<\/a><\/em> links use of azithromycin to an increased risk of cardiovascular death, a reminder that &#8220;azithro&#8221; is in fact a drug &#8212; and that all drugs have side effects.<\/p>\n<p>A few more musings on this extremely popular\u00a0antibiotic:<\/p>\n<ul>\n<li>Has there been anything even close to the universal &#8220;penetrance&#8221; of the 5-day, 6-pill &#8220;Z-Pak&#8221; in terms of outpatient antibiotic prescribing? Oddly enough, the first time I wrote for it way back in the early 1990s, the patient I gave it to thought he was being ripped off &#8212; not enough pills!<\/li>\n<li>Of course, that didn&#8217;t last long, many patients now ask for a &#8220;Z-Pak&#8221; by name. The marketing genius who came up with the &#8220;Z-Pak&#8221; should win the advertising equivalent of the Nobel Prize, even if he\/she would fail a first-grade spelling test.<\/li>\n<li>The ubiquitous toy zebras probably didn&#8217;t hurt pediatric prescribing either. These trinkets are now forbidden, but\u00a0<strong><a href=\"http:\/\/www.ebay.com\/itm\/Pfizer-1999-Plush-Advertising-ZEBRA-Zithromax-Bean-8-\/200601988861?pt=LH_DefaultDomain_0&amp;hash=item2eb4cf6efd#ht_6658wt_906\" target=\"_blank\" rel=\"noopener\">you can pick one up on eBay<\/a><\/strong> if you&#8217;re feeling nostalgic.<\/li>\n<li>Initially, cost-cutters tried to get clinicians to prescribe erythromycin over azithro (and clarithro) since the newer macrolides were so much more expensive. Talk about a losing battle &#8212; sometimes newer is not just costly, it&#8217;s costly\u00a0and better. (Ditto fluconazole when it replaced ketoconazole.)<\/li>\n<li>Now that azithromycin and clarithromycin are both generic, does anyone regularly use clarithromycin anymore? Yes, it&#8217;s more active versus atypical mycobacteria, but hardly enough so to make it worth the increased drug-drug interactions, QT prolongation, excess mortality risk (as seen in prospective studies like\u00a0<strong><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/16339220\" target=\"_blank\" rel=\"noopener\">this one<\/a><\/strong>), and peculiar taste disturbance. (It was with clarithromycin that I learned the word\u00a0<a href=\"http:\/\/www.google.com\/search?sourceid=chrome&amp;ie=UTF-8&amp;q=define+dysgeusia\" target=\"_blank\" rel=\"noopener\"><strong>dysgeus<\/strong>ia<\/a> &#8212; it means distortion of taste &#8212;\u00a0\u00a0and a\u00a0<strong><a href=\"http:\/\/www.hopkinsglobalhealth.org\/researchers\/profile\/49\/Chaisson\/Richard_E.\" target=\"_blank\" rel=\"noopener\">famous mycobacterial researcher<\/a><\/strong> has a fascinating anecdote about how bizarre champagne tastes when accompanied by a side of Biaxin.)<\/li>\n<li>Department of Irony: \u00a0Azithromycin was studied as\u00a0<strong><a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa043526\" target=\"_blank\" rel=\"noopener\">treatment to prevent cardiac disease.<\/a><\/strong> You remember, treat\u00a0<em>Chlamydia pneumoniae,<\/em> that notorious &#8220;cause&#8221; of atherosclerosis, and reduce cardiac events. (It didn&#8217;t work.)<\/li>\n<li>Little-known fact: \u00a0Azithromycin was developed by a then-small\u00a0<strong><a href=\"http:\/\/www.wipo.int\/sme\/en\/case_studies\/pliva.htm\" target=\"_blank\" rel=\"noopener\">Croatian pharmaceutical company named Pliva<\/a><\/strong> in the 1970s, with a world-wide patent in 1981 &#8212; 10 years before it was FDA-approved in the USA. At its peak, Pfizer was making more than $1 billion\/year on azithromycin sales and, of course, sharing some of that with Pliva (and making stuffed zebras).<\/li>\n<li>The downside of all this azithromycin use? Predictably, increased rates of clinically important resistance &#8212; especially <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21890767\" target=\"_blank\" rel=\"noopener\"><strong><em>Strep pneumo<\/em><\/strong><\/a> and <strong><a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa013169#t=articleDiscussion\" target=\"_blank\" rel=\"noopener\">group A strep<\/a><\/strong>. Hard to believe that second-line treatment for pneumococcal pneumonia, back when I was in medical school,\u00a0was erythromycin. Yes, I might be old.<\/li>\n<\/ul>\n<p>If there&#8217;s a silver lining to this report in the <em>NEJM<\/em>, it&#8217;s that clinicians will stop prescribing azithromycin for conditions that clearly don&#8217;t need it &#8212; which is <em>just about every uncomplicated outpatient respiratory infection.<\/em><\/p>\n<p>Hey, we can dream, can&#8217;t we?<\/p>\n","protected":false},"excerpt":{"rendered":"<p>I&#8217;ve commented before about azithromycin, that remarkable antibiotic that clinicians seem to prescribe for, gosh, you-name-it. But a paper just published in the New England Journal of Medicine links use of azithromycin to an increased risk of cardiovascular death, a reminder that &#8220;azithro&#8221; is in fact a drug &#8212; and that all drugs have side [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8],"tags":[],"class_list":["post-1888","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/1888","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=1888"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/1888\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=1888"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=1888"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=1888"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}