HHE Respiratory 2019 | Page 21

SECTION LABEL thrice weekly (lower dose and smaller population (n=109) than AMAZES) with higher inhaled steroid doses and two exacerbations in the previous year. There was no significant difference in exacerbation rates compared with placebo. Patients from 18 to 75 years were eligible for entry to study. Overall there was a clear reduction in asthma exacerbations (both moderate and severe). This was seen for both eosinophilic and non- eosinophilic exacerbations with a greater reduction seen in eosinophilic groups. The majority of studies demonstrated improvement in asthma symptoms. Actual changes were minimal and unlikely to be of clinical significance (statistical significance was reached in only three studies). Azithromycin use may reduce bronchial hyper-responsiveness in asthma and might result in a reduction in oral steroid dose, but this is not a consistent finding. It can result in a small improvement in lung function and peak expiratory flow rate; it may also result in measurable improvements in quality of life (QoL) but the clinical impact of these changes remains unknown and may be very small. There is no evidence of the impact of macrolide therapy on mortality, exercise capacity, disease progression or sputum production in people with asthma, therefore no recommendations in regard to these outcomes can be made in this guideline. Avoid long-term macrolide use in smokers, as therapy would be ineffective Recommendation Oral macrolide therapy should be considered to reduce exacerbation frequency in adults (50–70 years), with ongoing symptoms despite >80% adherence to high-dose inhaled steroids (>800mcg/day of beclomethasone diproprionate equivalent) and at least one exacerbation requiring oral steroids in the past year. This recommendation reflects the population within the AMAZES 4 randomised, controlled trial (RCT), which represents the highest quality evidence of macrolide therapy leading to a significant reduction in exacerbations. Treat for 6–12 months’ duration, 500mg three-times a week. COPD There were nine RCTs reviewed, ranging from 3 to 12 months’ duration and using different macrolides. The mean ages of participants were 64–72 years. There was no evidence of improvement in lung function and no mortality benefit. There was a statistically significant improvement in QoL measured by the St George’s Respiratory Questionnaire (SGRQ), but not clinically significant four-unit improvement as 21 HHE 2019 | hospitalhealthcare.com