Hard-to-treat asthma can be a life-threatening lung disease. That’s why research from Australia suggesting that the antibiotic azithromycin (Zithromax) helps asthma is so exciting. The authors called their trial AMAZES (Asthma and Macrolides: AZithromycin Efficacy and Safety study). The results were very good, if not amazing. Could this antibiotic also be helpful against rosacea?
Asthma: A Changing Condition?
Asthma was once considered a serious but not life-threatening lung condition. William Osler, MD, has been described as the father of modern medicine. He was one of the founders of Johns Hopkins Medical School. Dr. Osler believed that no one died from asthma. He described the “asthmatic panting into old age.”
About 300 million people around the world have asthma, a chronic inflammation of the airways that causes wheezing and difficulty breathing. (According to the American Lung Association and the CDC, the current figure in the US is 26 million children and adults with asthma.) Thousands die each year and the financial costs top $50 billion.
Asthma Takes a Toll:
Such statistics do not capture the personal toll that asthma takes. Not being able to breathe is frightening. Some people curtail their activities in an attempt to avoid attacks. Others end up in the emergency room in acute distress, gasping for breath. Too many people die!
Some health professionals suggest that the reason for so many asthma deaths is that patients are “noncompliant.” We find that concept objectionable. Someone who is having difficulty breathing is highly motivated to get relief. As a teenager I (Joe) suffered from asthma. When you wake up in the middle of the night gasping for air the first thing you reach for is your inhaler.
Most people take their medicine because the memory of a severe asthma attack does not fade. In our opinion, asthmatics are highly motivated to comply with a prescribed regimen and prevent another serious attack and/or a trip to the emergency department.
Drugs for Asthma:
The usual treatments for asthma include inhaled corticosteroids such as fluticasone (Flovent), budesonide (Pulmicort) or mometasone (Asmanex). These help to control inflammation.
Many people also need medication to open airways (bronchodilators). The oldest and simplest would be drugs like albuterol (ProAir HFA, Ventolin HFA). Salmeterol and formoterol are long-acting bronchodilators that are often combined with corticosteroids. Brands include Advair, Dulera and Symbicort.
Leukotriene modifiers like montelukast (Singulair) or zileuton (Zyflo) calm the immune system and reduce inflammation. Doctors may prescribe them in addition to other medications, especially to people whose asthma appears to be triggered by allergies. One side effect of montelukast has surprised a lot of people, though. Depression and thoughts of suicide is a worrisome adverse reaction. You can read about that scandal at this link.
Hard-To-Treat Asthma:
Despite standard medical treatment, a certain proportion of asthma sufferers continue to have serious breathing difficulty. They may experience asthma exacerbations that can land them in the emergency department. In fact, nearly two million ER visits annually are due to asthma attacks. No wonder doctors have been anxious to find a way to reduce these complications.
Azithromycin for Asthma
A study from Australia (AMAZES) showed that adding the antibiotic azithromycin to the regular regimen made a significant difference (The Lancet, online July 4, 2017). Over 400 hard-to-treat patients were recruited. They received either azithromycin or placebo three times a week for 12 months in addition to their regular inhaled medication. The people who took the antibiotic had 40 percent fewer severe attacks and a better quality of life.
An editorial in The Lancet summarizes the importance of this research:
“…affordable, effective, and safe add-on therapies in patients with poorly controlled asthma are needed. Previous studies have shown a beneficial effect of macrolide antibiotics such as azithromycin on asthma symptoms, but their effect on asthma exacerbations has been inconclusive due to a lack of large long-term trials.”
The authors go on to note:
“Azithromycin improved asthma-related quality of life across all domains of the Asthma-specific Quality of Life Questionnaire. Additionally, azithromycin use was associated with improved asthma control, reduced the number of patients reporting a respiratory tract infection, and lowered the rate of antibiotic courses for respiratory indications. Importantly, azithromycin was generally safe and well tolerated, though diarrhoea was more frequent in users of azithromycin than placebo (34% vs 19%).”
In conclusion:
“…add-on therapy with azithromycin is effective and safe in adult patients with uncontrolled asthma despite treatment with inhaled corticosteroids and long-acting beta agonists.”
An Update on the AMAZES Clinical Trial:
In August, 2024 there was a “secondary analysis” of the AMAZES trial (Chest, Aug. 2024).
The authors asked this question:
“Does adding azithromycin to standard therapy in patients with persistent uncontrolled asthma induce remission compared with placebo?”
Here is what they found:
“This post hoc analysis was conducted to determine the proportion of people with asthma who had inhaled corticosteroid/long-acting beta-agonist treatment-resistant asthma treated with long-term azithromycin who achieved asthma remission and to compare the remission rate between treatment and placebo groups. The analysis was performed by applying various predefined composite definitions of asthma remission to the AMAZES clinical trial cohort. Over one-half of the study population treated with azithromycin achieved clinical remission and clinical remission plus lung function criteria. The remission rate was consistently higher in the azithromycin arm than the placebo arm. All primary, secondary, and sensitivity analyses favored the treatment arm. These results demonstrate that on-treatment clinical remission is a realistic goal for those who are treated with long-term azithromycin.”
We apologize for the technical language, but it proved long-lasting benefit of this antibiotic in hard-to-treat asthma patients. The authors close with this interpretation:
“The positive trend observed in this study raises the hope of asthma remission as a realistic therapeutic goal.”
Dr. David Hahn, Vindicated at Last!
This isn’t the first time we have heard that azithromycin for asthma could be helpful for hard-to-treat patients. Although it is not yet considered standard treatment, researchers have been reporting potential benefit for more than two decades (Presse Medicale, Feb. 4, 1995).
David Hahn, MD, MS, has been researching the potential infectious nature of asthma for more than 25 years (JAMA, July 10, 1991). For much of that time he was a voice in the wilderness. He discovered that many hard-to-treat patients responded to antibiotic therapy, in particular azithromycin. The research from Australia appears to confirm his approach.
New Research Will Consider Azithromycin for Personalized Treatment of Asthma:
Dr. Hahn brought this research proposal to our attention. It is sponsored by PCORI, the Patient-Centered Outcomes Research Institute. This independent nonprofit program aims to empower patients by funding research about problems that matter to patients. The proposed study on asthma will be on individualizing care, including azithromycin along with inhaled corticosteroids. If you have been troubled with asthma exacerbations, even though you use your inhaler as you should, you may want to consider participating. The researchers will be looking for biomarkers indicating infections as well as overall asthma control.
Learn More about Azithromycin for Asthma:
Listen to Dr. David Hahn describe his efforts to bring this research to the attention of his colleagues and directly to patients. Here is an interview with Dr. Hahn we conducted a few years ago. The mp3 download of the show is available for free. Make sure you click on the correct mp3 arrows (above the orange box) to get your free download.
Here is a link to Jim’s Story: Reclaiming a Life Nearly Ruined by Sudden-Onset Asthma. In it you will learn how Dr. Hahn’s antibiotic therapy helped Jim overcome close calls with asthma.
If you would like to read my story (Joe), here is a link to: “How I Overcame Asthma That Would Not Quit.”
The Benefits & Risks of Azithromycin for Asthma:
Dr. David Hahn explains the pros and cons and a unique once-a-week protocol for azithromycin treatment of hard-to-treat asthma. You can read about it in his book, A Cure for Asthma? What Your Doctor Isn’t Telling You–and Why. It is available at www.PeoplesPharmacy.com.
One reader shared this experience:
“My son was cured of moderate asthma after twelve years of suffering with asthma attacks. Zithromax works.
“My five-year-old grandson is now being treated with Zithromax for asthma. He says he feels like a new person already and his treatment still has a few weeks to go.”
Like any medication, azithromycin can have side effects. People with a particular heart rhythm abnormality (long QT interval) should not take this antibiotic. The Australian study did not include them. It also excluded people with hearing loss, since macrolide antibiotics like azithromycin can make hearing loss worse.
The authors of the AMAZES report conclude:
“…in patients who remain symptomatic on maintenance therapy, we consider that azithromycin is a valuable addition to existing regimens for treating asthma.”
To learn more about azithromycin for asthma, here is a link to Dr. Hahn’s book:
A Cure for Asthma? What Your Doctor Isn’t Tellling You–and Why.
Azithromycin and Rosacea:
We recently received this intriguing story from a reader:
Q. After my doctor prescribed azithromycin to take care of a Campylobacter bowel infection (my punishment for drinking the water during a visit to Romania), I was surprised that three days of this antibiotic obliterated my rosacea. The effect lasted for three months! Now, of course, I have a prescription for azithromycin from my dermatologist.
A. We are intrigued by your report. Rosacea is an inflammatory condition of the skin on the face characterized by facial flushing, redness, inflamed blood vessels and bumps that resemble pimples (although they are not).
Researchers believe that disruptions in the skin microbiome may be responsible in part for rosacea (Journal of Drugs in Dermatology, June 1, 2019). Possibly some of the inflammation is related to the body trying to respond to pathogens. That might help explain why you have responded so well to the antibiotic azithromycin.
Dermatologists have known for years that oral antibiotics can sometimes be surprisingly effective in the management of rosacea (Journal of Drugs in Dermatology, June 1, 2019). They also prescribe topical ivermectin (Soolantra) to treat this condition. It often responds well to this anti-parasitic agent.
Final Words:
We have long known that there is a microbiome of the intestinal tract. Trillions of bacteria, viruses and fungi inhabit our colon. Sometimes they live in harmony and sometimes the balance gets upset. That can lead to all sorts of gastrointestinal challenges.
We are also learning that there is a microbiome in our scalp, skin, brain and lungs. In other words, there are pathogens just about everywhere on and in our bodies. Eradicating the infectious agents when they cause mischief can sometimes be helpful. Dr. Hahn came up with a “metronomic” dosing schedule for asthma. A “metronome” can help a pianist or guitarist practice to a certain tempo. They help with timing. Metronomic chemotherapy may allow oncologists to provide anti-cancer drugs weekly over a long period of time to better control a malignancy.
Dr. Hahn developed the same concept for asthma. Instead of a continuous dose for days on end, he learned to treat for just a few days at a time but he repeated that relatively low dose on and off for months at a time to eradicate the bacteria. You can learn more about that approach in his book: A Cure for Asthma? What Your Doctor Isn’t Tellling You–and Why.
Most infectious disease experts are not comfortable with such an approach. But the AMAZES clinical trial suggests that azithromycin has some interesting potential against hard-to-treat asthma in selective patients.
