Macrolide Antibiotics and the Risk of Cardiac Arrhythmias

• Published in: American journal of respiratory and critical care medicine Vol. 189; no. 10; pp. 1173 - 1180
• Main Authors: Albert, Richard K., Schuller, Joseph L.
• Format: Journal Article
• Language: English
• Published: New York, NY American Thoracic Society 15.05.2014
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anti-Bacterial Agents - administration & dosage; Anti-Bacterial Agents - adverse effects; Antibiotics; Arrhythmias, Cardiac - chemically induced; Arrhythmias, Cardiac - physiopathology; Azithromycin - administration & dosage; Azithromycin - adverse effects; Biological and medical sciences; Cardiac arrhythmia; Cardiac dysrhythmias; Cardiology. Vascular system; Chronic obstructive pulmonary disease; Concise Clinical Review; Congenital diseases; Cystic fibrosis; Cystic Fibrosis - complications; Drug dosages; Heart; Heart Conduction System - drug effects; Heart Conduction System - physiopathology; Heart rate; Humans; Intensive care medicine; Macrolides - administration & dosage; Macrolides - adverse effects; Medical sciences; Mutation; Observational studies; Patients; Pneumology; Potassium; Pulmonary Disease, Chronic Obstructive - drug therapy; Pulmonary Disease, Chronic Obstructive - etiology; Randomized Controlled Trials as Topic; Risk Factors; Transplants & implants; Heart; Intensive care; Arrhythmia; Respiratory disease; Azithromycin; Prolonged QT interval; Cardiovascular disease; Risk; Conduction disorder; Macrolide; Antibiotic; QT prolongation; arrhythmias; Heart block; Heart disease; Risk factor; Antibacterial agent; Resuscitation
• DOI: 10.1164/rccm.201402-0385CI
• ISSN: 1073-449X; 1535-4970

Randomized, controlled trials have demonstrated that chronic therapy with macrolide antibiotics reduces the morbidity of patients with cystic fibrosis, non-cystic fibrosis bronchiectasis, chronic obstructive pulmonary disease, and nontuberculous mycobacterial infections. Lower levels of evidence indicate that chronic macrolides are also effective in treating patients with panbronchiolitis, bronchiolitis obliterans, and rejection after lung transplant. Macrolides are known to cause torsade des pointes and other ventricular arrhythmias, and a recent observational study prompted the FDA to strengthen the Warnings and Precautions section of azithromycin drug labels. This summary describes the electrophysiological effects of macrolides, reviews literature indicating that the large majority of subjects experiencing cardiac arrhythmias from macrolides have coexisting risk factors and that the incidence of arrhythmias in absence of coexisting risk factors is very low, examines recently published studies describing the relative risk of arrhythmias from macrolides, and concludes that this risk has been overestimated and suggests an approach to patient evaluation that should reduce the relative risk and the incidence of arrhythmias to the point that chronic macrolides can be used safely in the majority of subjects for whom they are recommended.