From the FDA Drug Label
Azithromycin tablets can be taken with or without food. Renal Insufficiency No dosage adjustment is recommended for subjects with renal impairment (GFR ≤80 mL/min) The mean AUC0-120 was similar in subjects with GFR 10 to 80 mL/min compared to subjects with normal renal function, whereas it increased 35% in subjects with GFR <10 mL/min compared to subjects with normal renal function. Caution should be exercised when azithromycin is administered to subjects with severe renal impairment. Acute bacterial exacerbations of chronic obstructive pulmonary disease (mild to moderate) 500 mg QD × 3 days OR 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5
For a dialysis patient with COPD exacerbation, the recommended dosage of azithromycin is:
- 500 mg QD × 3 days
- Alternatively, 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 However, caution should be exercised when administering azithromycin to patients with severe renal impairment, as the AUC0-120 increased by 35% in subjects with GFR <10 mL/min compared to those with normal renal function 1.
From the Research
For COPD exacerbation in dialysis patients, azithromycin is typically dosed at 250 mg three times a week, as this regimen has been shown to reduce the frequency of exacerbations without significant differences in efficacy compared to higher doses 2. No dose adjustment is required for patients on dialysis as azithromycin is primarily eliminated through biliary excretion rather than renal clearance. The medication should be taken at least 1 hour before or 2 hours after meals for optimal absorption. Patients should complete the full course even if symptoms improve before completion. Azithromycin works by inhibiting bacterial protein synthesis and has anti-inflammatory properties that are beneficial in COPD exacerbations. It's effective against common respiratory pathogens including Haemophilus influenzae, Moraxella catarrhalis, and atypical organisms. Some key points to consider when prescribing azithromycin for COPD exacerbation in dialysis patients include:
- Monitoring for potential side effects including QT prolongation, especially if the patient is on other medications that affect cardiac conduction 3.
- Caution is advised if the patient has severe liver disease, as azithromycin is metabolized in the liver 4.
- The use of azithromycin prophylaxis in older patients with frequent AECOPD should be determined on a case-by-case basis after careful review, discussion, and counseling of the potential benefits and risks 3.
- Long-term azithromycin therapy has been shown to reduce the frequency of COPD exacerbations and decrease emergency visits and hospital admissions in severe COPD patients 5. Some of the benefits of azithromycin in COPD exacerbation include:
- Reduction in the number of exacerbations per patient per year 4, 5.
- Decrease in emergency visits and hospital admissions 5.
- Improvement in quality of life, although the evidence is not conclusive 6. However, it is essential to weigh these benefits against the potential risks, including:
- Development of antibiotic resistance 3, 6.
- Adverse effects, such as QT prolongation and liver toxicity 4, 3. In conclusion, the most recent and highest quality study 2 supports the use of low-dose azithromycin (250 mg three times a week) for COPD exacerbation in dialysis patients, as it reduces the frequency of exacerbations without significant differences in efficacy compared to higher doses.