© 2006 American Thoracic Society
Azithromycin in Bronchiolitis Obliterans: Is the Evidence Strong Enough?To the Editor:As transplant pulmonologists, we are continuously faced with the desperation of our patients with chronic rejection due to the lack of effective therapy to improve this disorder. Azithromycin has recently been introduced into the armamentarium of medications for treatment of bronchiolitis obliterans syndrome (BOS). In a pilot study published in AJRCCM, Gerhardt and colleagues reported on the use of azithromycin in six patients, of which five had significant improvement in pulmonary function testing (1). After the publication of this article, multiple centers, including ours, began using azithromycin in patients with BOS who had failed conventional medical therapy. Our experience in the initial eight patients with BOS started on azithromycin and now followed for over a year did not replicate these results. None of our patients had improvement in airflow obstruction. The recent article by Yates and colleagues reports the experience with a select cohort of 20 patients at a large transplant center (2). The authors conclude that azithromycin reverses airflow obstruction in patients with BOS. The data presented in this article raise important questions about this therapy, and we echo the authors' caution that this therapy should not be viewed as a panacea for the treatment of BOS. Yates and coworkers report their results for FEV1 as a percentage of change from baseline. Although these changes appear dramatic in Figure 1 of the article, they do not necessarily reflect a clinical benefit for these patients. The mean FEV1 before initiation of therapy was 1.44 L (range, 0.54–3.28) and the mean improvement was 0.11 L (range, –0.07 to 0.73). This mean improvement represents an increase in FEV1 of 8% for the overall group. The results were reported after 3 months; however, by 6 months, 8 of 20 patients (40%) had no improvement (5 who had experienced initial improvement no longer sustained this improvement, and 3 patients did not experience improvement). Finally, the follow-up period was relatively short. Nevertheless, it is important to acknowledge that in the article by Yates and coworkers (2) as well as the original publication by Gerhardt and coworkers (1), there were some patients with BOS treated with azithromycin who did experience a significant improvement in pulmonary function. The objective, as mentioned in the accompanying editorial by Drs. Williams and Verleden, should be to conduct a large clinical trial with long-term follow-up to determine which patients might benefit from this therapy (3).
University of Texas Health Science Center, San Antonio, Texas FOOTNOTES Conflict of Interest Statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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