From the Guidelines
Bronchiolitis Obliterans Syndrome (BOS) is treated with low-dose azithromycin, with a recommended dose of 250 mg alternate days for a trial period of 3 months, as suggested by the British Thoracic Society guideline 1. This treatment approach is based on the conditional recommendation for treating BOS occurring in lung transplant recipients. The use of azithromycin in BOS treatment has been supported by various studies, including a retrospective study by Norman et al, which showed improvement in FEV1 and FVC following treatment with azithromycin, fluticasone, and montelukast (the FAM regime) 1. Some key points to consider in BOS treatment include:
- The FAM regimen has been shown to be effective in maintaining lung function in HSCT patients with BOS, with a lower incidence of treatment failure compared to historical controls 1.
- Prophylactic azithromycin has been studied in reducing the incidence of BOS in HSCT patients, with mixed results, but a multicentre open-labelled prospective study by Williams et al suggested a lower treatment failure rate with the FAM regimen 1.
- A single-centre RCT by Lam et al compared the effect of daily azithromycin with placebo in HSCT patients with BOS, but reported no change in lung function or quality of life (QOL) 1. However, the most recent and highest quality study, the British Thoracic Society guideline, recommends the use of low-dose azithromycin for treating BOS, prioritizing morbidity, mortality, and quality of life as the outcome 1.
From the Research
Treatment Options for Hyperhidrosis
- Topical aluminum chloride solution is the initial treatment in most cases of primary focal hyperhidrosis 2
- Topical glycopyrrolate is first-line treatment for craniofacial sweating 2
- Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis 2, 3
- Iontophoresis should be considered for treating hyperhidrosis of the palms and soles 2, 3, 4
- Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail 2, 3
- Local microwave therapy is a newer treatment option for axillary hyperhidrosis 2
- Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies 2, 3
Specific Treatment Approaches
- For axillary hyperhidrosis, botulinum toxin injections are recommended as second-line treatment, oral medications as third-line treatment, local surgery as fourth-line treatment, and ETS as fifth-line treatment 3
- For palmar and plantar hyperhidrosis, a trial of oral medications (glycopyrrolate 1-2 mg once or twice daily) is considered second-line therapy, iontophoresis is considered third-line therapy, and botulinum toxin injections are considered fourth-line treatment 3
- For craniofacial hyperhidrosis, oral medications (either glycopyrrolate or clonidine) are considered first-line therapy, and ETS is an option for severe cases 3
- Combination therapy with aluminum chloride hexahydrate and botulinum toxin type A can be effective for moderate to severe hyperhidrosis 5
- Topical glycopyrrolate can be effective in treating compensatory gustatory hyperhidrosis 6
- Botulinum toxin therapy showed significant improvement in palmar hyperhidrosis compared to iontophoresis with topical aluminum chloride hexahydrate 4