Azithromycin May Reduce Cholestasis in Primary Sclerosing Cholangitis: A Case Report and Serendipitous Observation

Abstract

The newer macrolides have been shown to exert additional anti-inflammatory effects. We report the possible effect of azithromycin on primary sclerosing cholangitis in a patient treated with the drug for severe asthma. A 45-year-old woman with Crohn's disease and primary sclerosing cholangitis, also suffering from severe asthma, was treated with azithromycin 500 mg OD for 3 consecutive days a week because of the clinical suspicion of bronchiectasis and the severity of her asthma. When the therapy was discontinued, her urine again became darker, pruritus reappeared with the usual severity and laboratory parameters, evaluated after 6 weeks without azithromycin, also worsened. For these reasons macrolide treatment was re-established. Cholestasis-related symptoms and the dark colour of the urine were again reduced 6 weeks later and laboratory parameters were again reversed. We are therefore tempted to speculate that azithromycin may have an effect on primary sclerosing cholangitis on the basis of its anti-inflammatory properties.

Randomised clinical trial: vancomycin or metronidazole in patients with primary sclerosing cholangitis ‐ a pilot study

“…38 Boner et al found a decrease in cholestasis-related signs and symptoms over 5 months of azithromycin treatment in a patient previously diagnosed with PSC; the azithromycin was originally prescribed to treat severe reactive airways disease, and the patient continued to take it after experiencing improvement in several clinical symptoms. 33 Cox et al reported three children with PSC and IBD who experienced normalisation of liver tests and resolution of symptoms with oral vancomycin treatment. 28 A recent pilot study from the same group evaluated 14 children diagnosed with PSC and IBD who were treated with oral vancomycin for 54 AE 43 months…”

“…reactive airways disease, after which incidental improvement of PSC was noted). 28,29,[32][33][34][35][36] Given the evidence supporting the PSC microbiota hypothesis yet the limited studies investigating the potential therapeutic effects of antibiotics, we conducted a randomised, double-blind pilot study of oral vancomycin or metronidazole as a treatment for patients with PSC. We chose these agents based on prior experience and evidence of seemingly greater therapeutic response.…”

Pathogenesis and clinical spectrum of primary sclerosing cholangitis

“…The use of non-absorbable antibiotics, such as vancomycin, demonstrated improvement in liver chemistries in a small subset of patients[121]. An improvement in liver biochemistries was also observed with use of absorbable antimicrobials including metronidazole, azithromycin, and minocycline[122-124]. More data points are necessary to provide the clinician with definitive and accurate treatment options for PSC.…”

Update on primary sclerosing cholangitis

“…In a trial of 14 pediatric patients with PSC [131], significant improvement in hepatic biochemistries was observed, paralleling increased levels of regulatory T-cells. Regarding absorbable antibiotics, improvements in hepatic biochemistries have also been observed for metronidazole [132], azithromycin [133] and minocycline [134], altogether suggesting that liver affection in PSC may be influenced by antimicrobial therapies. We anticipate that upon the further characterization of metagenomic components in PSC pathogenesis (Fig.…”