(Chest. 2004;125:70S-78S.)
© 2004
American College of Chest Physicians
Immunomodulatory Activity and Effectiveness of Macrolides in Chronic Airway Disease*
Bruce K. Rubin, MEngr, MD, FCCP and
Markus O. Henke, MD
* From the Department of Pediatrics (Dr. Rubin), Wake Forest University School of Medicine, Winston-Salem, NC; and Department of Pulmonary Medicine (Dr. Henke), Philipps-University Marburg, Marburg, Germany.
Correspondence to: Bruce K. Rubin, MD, MEngr, FCCP, Professor and Vice-Chair, Department of Pediatrics, Professor of Biomedical Engineering, Physiology, and Pharmacology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1081; e-mail: brubin{at}wfubmc.edu
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Abstract
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The use of troleandomycin as adjunctive therapy for the treatment of patients with corticosteroid-dependent asthma first suggested an immunomodulatory effect of the macrolide antibiotics. This led to studies of the macrolides in other chronic airway diseases, such as diffuse panbronchiolitis (DPB), a disease occurring primarily in East Asia. The use of macrolides for the therapy of patients with DPB has led to dramatic improvements in pulmonary function and prolonged survival. Similar benefits have been documented in Japanese studies of bronchiectasis, chronic bronchitis, and sinobronchial syndrome. Clinical and pathologic similarities between DPB and cystic fibrosis (CF) led to the investigation of macrolides for the treatment of CF. Data now suggest that persons with CF will benefit from macrolide therapy. In vitro and in vivo studies suggest that macrolides may inhibit the pulmonary influx of neutrophils, inhibit the release of proinflammatory cytokines, protect the epithelium from bioactive phospholipids, and improve the transportability of airway secretions. The immunomodulatory effects of the macrolides also may be beneficial for the treatment of other chronic inflammatory conditions.
Key Words: azithromycin • clarithromycin • cystic fibrosis • cytokines • diffuse panbronchiolitis • erythromycin • macrolide antibiotics • neutrophil • troleandomycin
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Introduction
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Interest in the immunomodulatory effects of macrolide antibiotics began with the observation that patients with severe asthma required lower doses of steroids if they also had received troleandomycin (TAO).1
Subsequently, macrolides have been studied for other airway diseases including diffuse panbronchiolitis (DPB) and cystic fibrosis (CF). The most convincing demonstration of the immunomodulatory effects of macrolides has been in the treatment of DPB, a pulmonary disease of unknown etiology that is found primarily in Japan. In 1984, the 5-year survival rate for DPB was only 26%, but treatment with macrolides has dramatically increased the 10-year survival rate of these patients to 94%.2
The effectiveness of these drugs appears to be limited to the 14-membered and 15-membered macrolides, such as erythromycin, clarithromycin, and azithromycin. These drugs improve pulmonary function, and decrease morbidity and mortality in patients with DPB.2
3
4
5
These macrolides decrease proinflammatory cytokines in serum and BAL fluid (BALF), decrease mucus hypersecretion, and may protect the airway epithelium from damage.6
7
8
CF is similar to DPB in many ways including symptoms and pulmonary pathology. Both diseases are characterized by cough, persistent sinus disease, neutrophilic airway inflammation, susceptibility to persistent endobronchial infection with opportunistic pathogens, and progressive deterioration in pulmonary function, and both diseases are responsive to the immunomodulatory effects of macrolides. This article reviews the immunomodulatory effects of macrolides, and the evidence for their clinical efficacy for the treatment of DPB and CF.
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The Steroid-Sparing Effects of Macrolides
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A number of studies9
10
11
12
13
14
have shown an improvement in the clinical symptoms of corticosteroid-dependent patients with asthma and a reduction in corticosteroid dosage with concomitant TAO therapy. Pharmacokinetic studies15
16
have suggested that the beneficial effects of TAO therapy may be due, in part, to the inhibition of steroid metabolism. TAO was shown to significantly prolong the serum half-life of methylprednisolone. However, in reported studies, some steroid-dependent patients were able to completely discontinue concomitant oral steroid therapy without worsening asthma severity, suggesting that TAO had direct anti-inflammatory activities. Studies14
17
also have shown that low-dose TAO directly attenuates bronchial hyperresponsiveness in children with severe asthma and that the effects were independent of its action on glucocorticoid metabolism. In another study, TAO appeared to inhibit T-cell proliferation in peripheral blood mononuclear cells from patients with steroid-resistant asthma.18
In this supplement to CHEST, Gotfried describes more recent studies designed to assess the direct effects of clarithromycin in adults with severe persistent asthma (see page 52S).
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The Effects of Macrolides on Mucus Secretion
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Macrolide antibiotics also appear to be mucoregulatory, that is, they are able to decrease mucus hypersecretion in persons with airway disease without suppressing baseline physiologic secretion. In a double-blind, placebo-controlled, 8-week trial of 31 patients with chronic bronchitis, bronchiectasis, or DPB, low-dose clarithromycin (100 mg twice daily) profoundly decreased the expectorated sputum volume from 51 to 24 g per day (p < 0.001).19
Treatment with clarithromycin also increased the percentage of solid composition and the elastic modulus of the sputum (p < 0.05) but did not alter its dynamic viscosity. Based on these data, the investigators suggested that clarithromycin reduces both mucus and water secretion. Clarithromycin also significantly reduced the volume of nasal mucus secretion, both at baseline and with methacholine stimulation, and improved the sneeze (airflow) transportability in 10 patients with purulent rhinitis.20
Roxithromycin therapy for 12 weeks significantly decreased sputum volume and "purulence" in 25 children with bronchiectasis.21
The mechanism by which macrolides inhibit mucus hypersecretion is thought to involve decreasing the inflammatory stimulus for hypersecretion.22
23
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The Effects of Macrolides on DPB
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DPB is a chronic inflammatory pulmonary disease that is well-recognized in Japan and Korea, and is less commonly diagnosed in the West.24
25
26
Although upper airway symptoms, including chronic sinusitis, usually begin in late childhood, DPB is usually diagnosed between the second and fifth decades of life, and is characterized by chronic, progressive, obstructive, and inflammatory sinobronchial disease. The clinical diagnostic criteria of DPB are given in Table 1
.2
These criteria include airflow limitation, sinusitis, sputum expectoration, dyspnea, and chronic airway infection, often with mucoid Pseudomonas aeruginosa. The results of pulmonary function tests typically show a mixed obstructive/restrictive picture similar to that for CF. Radiographic findings include reticular or nodular shadows, and CT scans show the characteristic central nodules with a tree-in-bud appearance.26
27
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Clinical Studies
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Kudoh and colleagues27
were the first to demonstrate that low-dose erythromycin ameliorated the signs and symptoms of DPB. Therapy often will improve the appearance of chest radiographs and normalize pulmonary function. A large number of studies3
5
27
28
have confirmed the effectiveness of long-term macrolide therapy for the treatment of DPB. These are summarized here.
In a retrospective analysis of 498 Japanese patients with DPB,2
a significant improvement in survival was associated with treatment using 400 to 600 mg daily of erythromycin. Subjects were categorized into one of three groups based on the date of the initial diagnosis. Group A included 190 subjects who had received diagnoses between 1970 and 1979, group B included 221 subjects who had received diagnoses between 1980 and 1984, and group C included 87 subjects who had received diagnoses between 1985 and 1990. A comparison of Kaplan-Meier survival curves of subjects in each group (Fig 1 ) showed significantly improved survival for the 63 patients in group C who had been treated with erythromycin compared with those in group A (p < 0.0001), group B (p < 0.0001), and 24 patients from group C who had not been treated with erythromycin (p < 0.0056). The 5-year survival rates of subjects not treated with erythromycin in groups A and C did not differ significantly.
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Figure 1. The survival rate of patients treated with erythromycin (group c EM+) was significantly greater than that of untreated patients (group c EM-) [p < 0.0056]. Untreated patients were not different from historical control subjects (group a) [p < 0.2475]. This figure was adapted with permission from Kudoh et al.2
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The long-term efficacy and safety of clarithromycin was evaluated in 10 subjects with DPB who were treated for 4 years with clarithromycin, 200 mg per day.3
Pulmonary function improved in most subjects within 6 months of initiating treatment with clarithromycin. The FEV1 increased from 1.74 L at baseline to 2.31 L at 6 months (p < 0.01), and the FVC increased from 2.67 L at baseline to 3.16 L at 6 months (p < 0.005) [Fig 2
]. The resting PaO2 significantly increased within 3 months after beginning macrolide therapy (p < 0.05). Sputum cultures were positive for Haemophilus influenzae, Haemophilus parahaemolyticus, Streptococcus pneumoniae, and P aeruginosa at baseline but were negative within 6 months after beginning therapy. The treatment was well-tolerated, and clarithromycin provided a sustained clinical benefit.
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Figure 2. Top, A: Mean FEV1 increased within 3 months of beginning clarithromycin therapy in 10 subjects with DPB. A maximal value was reached at 6 months and was sustained for 4 years. Bottom, B: The FVC increased to a maximal level within 6 months of beginning clarithromycin and was sustained for 4 years. * = p < 0.01 compared to baseline; ** = p < 0.05 compared to baseline; ## = p < 0.005 compared to baseline. This figure was adapted with permission from Kadota et al.3
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Data from 28 subjects with DPB treated with erythromycin, 600 mg per day for 1 month, showed that the drug produced significant clinical improvement, and decreased the number of neutrophils and the concentration of interleukin (IL)-8 in BALF.29
These observations were independent of P aeruginosa infection in these subjects, suggesting a systemic, anti-inflammatory effect of erythromycin in patients with this disease.
The mechanism by which macrolides improve the symptoms of DPB probably includes inhibiting the pulmonary influx of neutrophils.6
30
In chronic inflammation of the airways, neutrophils accumulate in the airway secreting elastase, myeloperoxidase, and inflammatory mediators that can produce epithelial dysfunction. Many studies have evaluated the effects of macrolides on neutrophils. BALF from patients with DPB contains many neutrophils. Macrolides may inhibit the production or secretion of proinflammatory cytokines, which results in the reduced accumulation of neutrophils in the airway.31
In vitro studies32
have shown that macrolides inhibit the production of proinflammatory cytokines through the inhibition of transcription factors, nuclear factor 
B, and activator protein-1. In vitro data also suggest that macrolides may protect the epithelium from bioactive phospholipids and may improve the transportability of airway secretions.6
19
20
33
34
Treatment with erythromycin, 600 mg daily for 6 to 12 months, was associated with a reduction in both neutrophil number (p < 0.01) and neutrophil- derived elastolytic activity (p < 0.001) in the BALF of 11 subjects with DPB.35
This was associated with improved pulmonary function. In 19 subjects with DPB, treatment with erythromycin, 600 mg per day, or roxithromycin, 150 mg per day for 1 to 24 months, improved the FVC and FEV1 (p < 0.01), and reduced the percentage of neutrophils in BALF by 63.8% compared with baseline (p = 0.0001). A higher percentage of neutrophils and the concentration of IL-1ß are associated with increasing levels of IL-8 in the BALF of patients with DPB.36
37
IL-1ß, tumor necrosis factor (TNF)-
, and IL-8 were measured in the BALF of 19 subjects with DPB, and were compared with 7 healthy subjects and 17 subjects with pulmonary sarcoidosis, who served as disease controls.31
The pretreatment concentrations of IL-1ß and IL-8 in patients in the DPB group were higher than those of healthy subjects (p < 0.05) or of those with sarcoidosis (p < 0.01), and BALF concentrations of IL-1ß (p < 0.015) and IL-8 (p < 0.05) were significantly reduced following macrolide therapy (Fig 3
, left). In subjects with DPB, there was a significant correlation between the percentage of neutrophils and the concentration of IL-8, and the concentrations of IL-1ß and IL-8 (Fig 3
, right).
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Figure 3. Left: The level of IL-8 (mean ± SE) in the BALF of subjects with DPB was compared before and after macrolide therapy, and was compared to subjects with sarcoidosis (SAR) or healthy volunteers. Right: Correlation between the percentage of neutrophils and the levels of IL-8 in the BALF of 19 subjects with DPB (r = 0.509; p < 0.05). This figure was adapted with permission from Sakito et al.31
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In another study,39
macrolide therapy reduced neutrophil numbers, and the concentration of IL-8 in BALF in 14 subjects with DPB. It also improved the FVC percent predicted (p < 0.01), the FEV1 percent predicted (p < 0.02), and the PaO2 (p < 0.01) over pretreatment values.38
Macrolide therapy also significantly decreased the concentration of ß-defensin-2 but not ß-defensin-1 in BALF, or concentrations of ß-defensin-1 or ß-defensin-2 in the plasma of these subjects.39
ß-defensins are endogenous antimicrobial peptides, but they also may cause pulmonary injury.38
Similarly, 2 to 6 months treatment with clarithromycin, 200 mg per day, erythromycin, 600 mg per day, or roxithromycin, 150 mg per day, reduced the absolute number of lymphocytes and activated CD8+ cells in the BALF of subjects with DPB, with a corresponding increase in the CD4+/CD8+ ratio.40
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The Effects of Macrolides in CF
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Based on the similarities between DPB and CF, macrolide antibiotics have now been studied as immunomodulatory medications for the treatment of CF.41
42
In a pilot study,43
daily azithromycin was given for > 3 months (and up to a year) to 7 children aged 6 to 17 years with CF and P aeruginosa infection. During the study, no concomitant therapy with steroids, dornase alfa, or IV Ig was administered to these subjects. Excluding the first 2 months of treatment from their analysis, the authors compared mean FVC and FEV1 percent predicted values in the 6 months before starting azithromycin with those after therapy in the final month of the trial. The FVC rose from 62.8 to 70.3% predicted, with a median improvement of 11.3% (p < 0.03), and FEV1 percent predicted increased by 11.0% (p < 0.03).
This group at the Royal Brompton Hospital then conducted a 15-month randomized, double-blind, placebo-controlled, crossover trial44
of orally administered azithromycin therapy in 41 children (age range, 8 to 18 years) with CF. Subjects received either azithromycin or placebo for 6 months followed by a 2-month washout period, and then were crossed over to the other treatment group. The primary outcome measure was a change in FEV1. They also measured FVC, concentrations of IL-8 and neutrophil elastase (NE) in sputum, exercise tolerance using a 3-min step test, change in antibiotic usage, frequency of respiratory exacerbations, Pseudomonas colony counts, and quality of life. Subjects who weighed 
40 kg received either a single azithromycin tablet, 250 mg, daily or matching placebo, while subjects weighing > 40 kg received either two azithromycin tablets, 250 mg (total, 500 mg), or two matching placebo tablets daily. Fifteen of the 41 subjects (36.6%) continued the established treatment with dornase alfa.
The primary end point was FEV1, which improved by 5.4% (95% confidence interval [CI], 0.8 to 0.5%) with azithromycin compared with placebo in the fourth and sixth month treatment period visits (Fig 4
). Fifty percent of the children had an improvement in the primary end point of at least 10%. There was a suggestion that children who were homozygous for the deltaF508 mutation did better than the rest of the group. The mechanism of benefit could not be determined, in that there was no difference in sputum bacteriology results, sputum NE levels, or IL-8 levels. The authors did not assay NE activity, which could have been inhibited by azithromycin.
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Figure 4. Left, A: Mean (95% CI) change from baseline of FEV1 in 41 children with CF who were treated with azithromycin and placebo in a crossover trial. The mean FEV1 was greater during the azithromycin arm of the trial (p = 0.031). The median relative difference between azithromycin and placebo was 5.4% (95% CI, 0.8 to 10.5). Right, B: Mean (95% CI) change from baseline visit of FVC percent predicted for each treatment period. This figure was adapted with permission from Equi et al.44
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A post hoc comparison of the results in the groups of subjects either taking or not taking dornase alfa was conducted on the basis of an in vitro study,45
which suggested that azithromycin inhibits this enzyme. In this subgroup analysis, the children not inhaling dornase alfa (26 patients) had an increase in FEV1 of 11.5% (95% CI, 5.3 to 16.5), whereas those who also inhaled dornase alfa had a decrease of 3.6% (95% CI, -22 to 3.9). However, before recommending that patients taking azithromycin discontinue therapy with dornase alfa, it should be remembered that this may be a chance finding in a study not adequately powered for subgroup analysis, and so needs confirmation by other studies.
Wolter et al46
conducted a 3-month, prospective, randomized, double-blind trial of azithromycin, 250 mg daily, in 60 adults with CF. Clinically stable subjects ranging in age from 18 to 44 years were randomized to receive either azithromycin or placebo. Statistical analysis was adjusted for differences between the two groups in gender, weight, and baseline pulmonary function, but subjects were not stratified by disease severity. Monthly assessments included spirometry, body weight, sputum cultures with quantitative bacterial counts, serum C-reactive protein (CRP), and erythrocyte sedimentation rate as markers of systemic inflammation, and quality of life domains measured by the chronic respiratory disease questionnaire. The mean FEV1 and FVC were 56.6% predicted and 72.4% predicted, respectively, at the start of the study. Significant differences were measured between the azithromycin-treated and placebo-treated groups in change in FEV1 percent predicted (p = 0.047) and change in FVC percent predicted (p = 0.001). Subjects randomized to azithromycin maintained pulmonary function over the 3 months of the study, whereas patients receiving placebo had a deterioration of FEV1 percent predicted and FVC percent predicted. The azithromycin group also required fewer days of therapy with IV antibiotics (p = 0.009), fewer days at home receiving IV antibiotics (p = 0.037), and fewer courses of IV antibiotics (p = 0.016). Subjects randomized to azithromycin scored higher on improvements in dyspnea (p = 0.042), fatigue (p = 0.003), emotional (p = 0.012) and mastery domains (p = 0.035), and total scores (p = 0.035) of the chronic respiratory disease questionnaire compared with those in the placebo arm.
In the azithromycin group, the median CRP declined steadily over time, while serum levels remained relatively constant in the placebo group. In subjects who received azithromycin, the reduction in CRP strongly correlated with baseline CRP, which negatively correlated with the FEV1 percent predicted (p < 0.001). No significant between-group differences were reported in erythrocyte sedimentation rate, body mass index, bacterial types, or density. The subjects in this study represented an older CF population with more severe respiratory disease who received a relatively short course of azithromycin compared with those reported by Equi et al.44
Despite the differences in demographics and study design, both young and older subjects with CF responded to therapy with azithromycin, as reflected in the improved pulmonary function and quality of life.
In contrast to these studies, Ordonez et al47
failed to show a therapeutic benefit of macrolide therapy in a small pilot study of 10 adults (age range, 19 to 26 years) with CF and P aeruginosa infection. Subjects were treated with placebo for 3 weeks followed by 6 weeks of therapy with clarithromycin, 500 mg twice daily. Clarithromycin had no significant effect on pulmonary function, the number of neutrophils, or the concentrations of IL-8, NE, TNF-, and myeloperoxidase in induced sputum samples. The authors suggested that the lack of effect may have been due to there being too few subjects or too short of a treatment period, leading to a type 2 error.47
The Cystic Fibrosis Foundation sponsored a large trial that was presented at the North American Cystic Fibrosis Meeting in New Orleans in 2002. The design was parallel group, with a 2-week run-in period, a 168-day treatment period, and a 28-day washout period. The dose was 500 mg if the patient’s weight was 
40 kg, 250 mg if the patient’s weight was < 40 kg, and was given on 3 days in the week, with provision for stepdown to a lower dose if that dose was not tolerated. One hundred eighty-five patients were randomized, of whom 87 received azithromycin and 98 received placebo. Only one subject (in the placebo limb) did not complete the follow-up. The groups were well-matched. The mean age was 20 years, just over half were men, and the starting FEV1 was approximately 70% predicted. The results showed a treatment benefit of 0.093 L or 6.21% predicted for FEV1, and 4.95% for FVC (highly statistically significant). There was marked variation in the individual response. Approximately 12% of patients increased FEV1 by 15% while receiving azithromycin (none receiving placebo), but the conditions of some patients actually deteriorated. Any benefit was lost within 28 days of discontinuing therapy. The investigators reported a 40% reduction in infective exacerbations, but only the percentage of subjects hospitalized (patients receiving azithromycin, 16%; patients receiving placebo, 30%) reached statistical significance. The azithromycin group gained 800 g in weight compared with the placebo group at the end of the treatment period. This is important, because some macrolides are thought to be anorexigenic. Physical functioning on a quality-of-life score improved significantly while patients received azithromycin. There were no problems with the emergence of resistant microorganisms, with more new isolates of Staphylococcus aureus appearing in the placebo group. In terms of adverse events, nausea and diarrhea were common in the azithromycin group, which was not a surprise. What was surprising is that there was more wheezing reported in the azithromycin group despite improved lung function. One might speculate that this was due to secretions mobilizing in the major airways. There was no drug toxicity, and dose reduction or study drug discontinuation was rare and equally distributed between the two groups.
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Conclusion
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In nearly all reports, patients with DPB or CF who have received macrolide antibiotics have responded with dramatic improvements in pulmonary function. The treatment of DPB is the most striking example of the benefits of macrolides. Before the introduction of macrolide therapy, the 10-year survival rate was reported to be 12 to 50%,2
but since the introduction of macrolide therapy the 10-year survival rate is now > 90%. It is probable that patients with CF may realize similar benefits with long-term macrolide therapy. This is the focus for ongoing research. There is also strong clinical evidence for the effectiveness of macrolides in the treatment of bronchiectasis, chronic bronchitis, and sinusitis, as described in the review by Gotfried in this supplement.
Both in vivo and in vitro studies strongly support the immunomodulatory effects of macrolides. Further studies will determine which of the macrolides are the most effective, the duration of the effect, the long-term consequences of the long-term use of these antibiotics, and their mechanisms of action. This information may lead to the development of more specific therapeutic agents. Based on the effectiveness of macrolides for the treatment of DPB and CF, these drugs may be beneficial for the treatment of other chronic inflammatory respiratory conditions, as well as other nonrespiratory diseases such as chronic arthritis, inflammatory bowel disease, and chronic inflammatory skin conditions.
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CME Questions
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The American College of Chest Physicians designates this continuing medical education activity for 1 credit hour in category 1 of the Physician’s Recognition Award of the American Medical Association. To obtain credit, please complete the question form at http://www.chestnet.org. Credit can be obtained ONLY through our online process.
- Diagnostic criteria for DPB include all of the following except:
- FEV1 < 70% and PaO2 < 80 mm Hg
- Elevated titers of cold hemagglutinin x 64
- Bilateral fine nodular shadow
- Decreased sputum secretion
- History of parasinusitis
- Macrolides may inhibit the production of proinflammatory cytokines, which results in which of the following?
- Reduced accumulation of neutrophils in the airway
- Increased accumulation of neutrophils in the airway
- Inhibition of nuclear factor-B and activator protein-1
- Stimulation of nuclear factor-B and activator protein-1 production
- Stimulation of the CF transmembrane receptor function
- Which of the following in not a potential mechanism by which macrolides exert their effect for the treatment of DPB and CF?
- Supression of the CF transmembrane receptor function
- Protection from bioactive phospholipids
- Improvement in the mucociliary and cough transportability of airway secretions
- Expression of the
508 CF transmembrane receptor mutation
- Inhibition of proinflammatory cytokines
- Which of the following is not affected by macrolides?
- IL-8
- IL-1ß
- TNF-
- ß-defensins
- IL-2
- Which of the following has not been shown in clinical trials of macrolides for the treatment of DPB and CF?
- Increased sputum production
- Increased FEV1
- FVC
- Increased PaO2
- Increased quality of life
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Footnotes
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Abbreviations: BALF = BAL fluid; CF = cystic fibrosis; CI = confidence interval; CRP = C-reactive protein; DPB = diffuse panbronchiolitis; IL = interleukin; NE = neutrophil elastase; TAO = troleandomycin; TNF = tumor necrosis factor
Learning objectives:
- To be aware of the diagnostic criteria for DPB.
- To understand the clinical evidence for the efficacy of macrolides for the treatment of DPB and CF.
- To understand the potential immunomodulatory effects of macrolides for the treatment of chronic diseases of the airways.
- To understand the effects of macrolides on mucus secretion.
- To realize the immunomodulatory effects of macrolides are independent of their antimicrobial effects.
- To realize the clinical utility of these drugs for the treatment of chronic inflammatory conditions.
Neither Dr. Rubin, nor the department(s) with which he is affiliated, has received something of value (ie, any item, payment, or service valued in excess of $750.00) from a commercial or other party related directly or indirectly to the subject of this submission. He has received research grants and honoraria, and is a consultant for Abbott Laboratories. He has also received research grants from Zambon Pharmaceuticals. Neither Dr. Henke, nor the department(s) with which he is affiliated, has received something of value (ie, any item, payment, or service valued in excess of $750.00) from a commercial or other party related directly or indirectly to the subject of this submission. This article will be presenting information about immunomodulatory uses of macrolide antibiotics that is considered research and is not yet approved for any purpose.
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Abstract
Introduction
