A randomised controlled trial of azithromycin therapy in bronchiolitis obliterans syndrome (BOS) post lung transplantation

Abstract

<h3>Background</h3> We conducted a placebo-controlled trial of azithromycin therapy in bronchiolitis obliterans syndrome (BOS) post lung transplantation. <h3>Methods</h3> We compared azithromycin (250 mg alternate days, 12 weeks) with placebo. Primary outcome was FEV₁ change at 12 weeks. <h3>Results</h3> 48 patients were randomised; (25 azithromycin, 23 placebo). It was established, post randomisation that two did not have BOS. 46 patients were analysed as intention to treat (ITT) with 33 ‘Completers’. ITT analysis included placebo patients treated with open-label azithromycin after study withdrawal. <h3>Outcome</h3> The ITT analysis (n=46, 177 observations) estimated mean difference in FEV₁ between treatments (azithromycin minus placebo) was 0.035 L, with a 95% CI of −0.112 L to 0.182 L (p=0.6). Five withdrawals, who were identified at the end of the study as having been randomised to placebo (four with rapid loss in FEV₁, one withdrawn consent) had received rescue open-label azithromycin, with improvement in subsequent FEV₁ at 12 weeks. Study Completers showed an estimated mean difference in FEV₁ between treatment groups (azithromycin minus placebo) of 0.278 L, with 95% CI for the mean difference: 0.170 L to 0.386 L (p=&lt;0.001). Nine of 23 ITT patients in the azithromycin group had ≥10% gain in FEV₁ from baseline. No patients in the placebo group had ≥10% gain in FEV₁ from baseline while on placebo (p=0.002). Seven serious adverse events, three azithromycin, four in the placebo group, were deemed unrelated to study medication. <h3>Conclusions</h3> Azithromycin therapy improves FEV₁ in patients with BOS and appears superior to placebo. This study strengthens evidence for clinical practice of initiating azithromycin therapy in BOS. <h3>Trial registration number</h3> EU-CTR, 2006-000485-36/GB.