© 2006 American Thoracic Society
Azithromycin in Bronchiolitis Obliterans: Is the Evidence Strong Enough?From the Authors:Since our initial observation of significant and occasionally dramatic reversal of airflow obstruction in bronchiolitis obliterans syndrome (BOS) (1), other groups have described their experience with this novel therapeutic approach for this most devastating long-term complication of lung transplantation (2–4). Verleden and Dupont (2) and, more recently, Yates and colleagues (3) observed a favorable response to azithromycin in a sizable proportion of their respective series. The letter from Dr. Angel and colleagues questions the clinical significance of the improvement in airflow obstruction documented by Yates and coworkers. They also describe their own experience showing little long-term improvement for a small cohort of patients treated at their institution, mirroring the disappointing results by Shitrit and coworkers (4). Clearly, the response to azithromycin is quite variable, which is not unexpected, given the likely heterogeneous nature of the factors involved in the pathogenesis of this clinical syndrome. Perhaps those patients with active airway inflammation or bronchoalveolar lavage neutrophilia and/or elevated interleukin-8 concentrations are more apt to respond (5). We wholeheartedly agree with Dr. Angel and colleagues and Drs. Williams and Verleden (5) that a carefully designed, prospective, multicenter, randomized trial of azithromycin is needed urgently to determine conclusively whether this therapy is of benefit and to identify which patients are likely to respond. Given the lack of enthusiasm on the part of the pharmaceutical industry to support such a trial for a disease affecting a small patient population, alternative funding will be required. Recently, the National Institutes of Health convened a workshop on lung transplantation, with the expert panel concluding that multicenter studies were imperative (6). We believe the time has come to form a network of lung transplant centers to study important questions in lung transplantation, so as to move the field forward toward improved transplant outcomes and patient survival. We call on the National Institutes of Health to support such an initiative as suggested by the expert panel.
Johns Hopkins University, Baltimore, Maryland 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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