From the Guidelines
Long-term clarithromycin therapy for chronic rhinosinusitis (CRS) is not recommended as a routine treatment due to limited evidence supporting its use and potential risks of cardiovascular events and antimicrobial resistance. The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 1 states that the use of long-term antibiotics, including clarithromycin, has uncertain benefits and potential risks, and therefore, its use should be cautious.
Benefits and Risks
The benefits of long-term clarithromycin therapy for CRS are modest, with some studies showing improvements in nasal symptoms, polyp size, and quality of life measures in select patients 1. However, the risks associated with long-term macrolide therapy, including gastrointestinal disturbances, QT prolongation, and the risk of antimicrobial resistance, cannot be ignored 1.
Alternative Treatments
Intranasal corticosteroids have been shown to be effective and safe for treating patients with CRS, with high-quality evidence supporting their use 1. Alternative medicinal treatments, such as Chinese Herbal Medicine, have also been used with some benefits, although more research is needed to fully understand their effects 1.
Patient Selection and Monitoring
If long-term clarithromycin therapy is considered, it should be used in patients with refractory disease who have not responded to standard treatments, and under close monitoring for adverse effects and clinical response 1. Patients with a history of QT prolongation, ventricular cardiac arrhythmia, or hypokalaemia should not be given clarithromycin, and concomitant administration with certain medications, such as astemizole, cisapride, and pimozide, is contraindicated 1.
Comprehensive Treatment Plan
A comprehensive treatment plan for CRS should include intranasal corticosteroids, saline irrigation, and consideration of alternative treatments, with long-term clarithromycin therapy used cautiously and under close monitoring, if at all. The benefits and risks of long-term macrolide therapy should be weighed against the potential benefits of other treatments, and patients should be regularly assessed for clinical response and adverse effects.
From the Research
Long-term Use of Clarithromycin in Chronic Rhinosinusitis (CRS)
- The evidence suggests that long-term use of clarithromycin is effective in the treatment of CRS, with various studies indicating improved clinical symptoms, endoscopic scores, and quality of life 2, 3, 4, 5, 6.
- A systematic review and meta-analysis found that adding oral clarithromycin to intranasal steroid spray with or without nasal saline irrigation statistically significantly improved clinical symptoms, endoscopic scores, and computed tomography (CT) scores in the short, medium, and long term 3.
- Studies have also shown that long-term, low-dose clarithromycin treatment is effective and safe for the treatment of CRS without nasal polyps, with significant improvements in total nasal symptom scores, nasal resistance, and quality of life 4.
- In patients with chronic polypous rhinosinusitis, long-term clarithromycin therapy has been shown to be effective, with good and excellent effects observed mainly in patients with mild to moderate disease 5.
- A prospective study found that long-term adjuvant use of low-dose clarithromycin in patients with recurrent chronic rhinosinusitis with nasal polyps resulted in improved quality of life and nasal endoscopy findings, especially in patients with normal IgE levels 6.
Efficacy and Safety
- The evidence suggests that clarithromycin is well-tolerated, with no significant increase in adverse events compared to intranasal steroid spray alone 3.
- Long-term use of clarithromycin has been shown to be safe and effective, with significant improvements in clinical symptoms and quality of life 2, 4, 5, 6.
Patient Subgroups
- Studies have found that clarithromycin is effective in patients with CRS without nasal polyps, as well as in patients with chronic polypous rhinosinusitis 4, 5.
- A prospective study found that patients with normal IgE levels showed greater improvement in quality of life and nasal endoscopy findings with long-term adjuvant use of low-dose clarithromycin 6.